tag:blogger.com,1999:blog-42845777389240041962024-03-18T18:52:56.284-04:00Fibrinogen AmyloidosisDavidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.comBlogger194125tag:blogger.com,1999:blog-4284577738924004196.post-91930503082047837852024-01-02T06:51:00.000-05:002024-01-02T06:51:13.346-05:00Happy New Year!!!!!!!!!! !!<p><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;">Happy New Year greetings once again to all loyal followers of the Fibrinogen Amyloidosis blog. Well, another year has passed without a blog post. I'm still asymptomatic, based on lab results from my annual physical exam and a visit to a nephrologist. No news is good news in that area.</span></p><p><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;"><br /></span></p><p><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;">I did attend the biennial ATTR/Hereditary amyloidosis meeting in Chicago the last weekend of October. It was another huge turnout of close to 500 patients and family members. The picture below was taken from a back corner of the main meeting room, which was very wide and not very deep, so only about two-thirds of the seating is visible.</span></p><p><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;"><br /></span></p><div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTusA1Uvp8UvM1qYHYvuQmn8guPKMhhQ6abd7_MB8L98q0j7mvrWNNKb203_IREQB4bmPw-wlgvdkx2Lsq1wTLrxFebca4p-IOK7BdWBn3HM9G50Uw74s2IAjl9K8DFnvQ_M-B7MjYp_JI0YOW7D3iS7Mjs7Pr9pgYV4RMmnmLuI82i4FLFfA77nl9uz4/s4032/ChicagoA.jpg" imageanchor="1"><img border="0" data-original-height="3024" data-original-width="4032" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTusA1Uvp8UvM1qYHYvuQmn8guPKMhhQ6abd7_MB8L98q0j7mvrWNNKb203_IREQB4bmPw-wlgvdkx2Lsq1wTLrxFebca4p-IOK7BdWBn3HM9G50Uw74s2IAjl9K8DFnvQ_M-B7MjYp_JI0YOW7D3iS7Mjs7Pr9pgYV4RMmnmLuI82i4FLFfA77nl9uz4/w400-h300/ChicagoA.jpg" width="400" /></a></div><br /><p><br /></p><p>This was the first of these meetings since 2019 because the one in 2021 was cancelled due to the COVID pandemic. I did not write a separate blog post about this meeting since there was not much to report regarding fibrinogen amyloidosis, but I did come away with a few observations:</p><div style="text-align: left;"><span style="color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small;"><br /></span></div><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg70WXYTXdy6ySn6KgzIkhOG_ceFa4lgUZbQCuOuuhQOKalb3u1VnvEEHK3uHz0qAI242A6HxpSt1epAkCy2zisJg0bmRP7SzwBExV08K3xpkzzNhZw0Ydwaya27-SaTKSCEWpNAeIhS5HXlOY6T7a7tDdGe9CfMXqNik8b2NDTN_iM6vjuga6lLaoeZ8M/s4032/Chicago.jpg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em; text-align: right;"><br /></a></div></span><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;"><div style="text-align: left;">1) The treatment options for ATTR amyloidosis, and the prognosis for those patients, have significantly improved since the first time I attended one of these meetings which was in 2011. I remember in 2011 one of the main topics of discussion at that meeting was organ transplants, and there were many patients there with double or triple organ transplants. And I believe only two or three drug treatments for ATTR undergoing clinical trials were discussed at that meeting. Compare that to the 2023 meeting, where organ transplantation was not even on the agenda yet there were presentations by six or seven different pharmaceutical companies regarding drugs they have under development or in clinical trials.</div></span><br style="color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small;" /><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;">2) I did ask the doctors in one of the breakout sessions if there were any drugs on the horizon for treating any of the non-ATTR hereditary types of amyloidosis, and they were not aware of any. So right now I honestly think our best hope for a drug treatment will be a drug that clears amyloid deposits of any kind from the body. One company working in that direction is Attralus, who did present at the Chicago meeting. Here are a couple of links to pages on the Attralus web site related to this activity, which they refer to as Pan-Amyloid Removal, or PAR:</span><br style="color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small;" /><br style="color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small;" /><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;">https://attralus.com/science#pan-amyloid-removal</span><br style="color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small;" /><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;">https://attralus.com/pipeline</span><br style="color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small;" /><br style="color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small;" /><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;">Although Attralus is in the very early stages of of their development, I think there is reason to be optimistic if you look at the progression of ATTR treatments over the past 10 to 15 years. Right now I think Attralus is the one to watch.</span><br style="color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small;" /><br style="color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small;" /><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;">Something else I did related to amyloidosis this year was attend the American Society of Hematology convention in San Diego in December. I did this as a volunteer for Amyloidosis Support Groups (ASG web site: https://www.amyloidosissupport.org/), which is a nonprofit patient advocacy group most of you are probably familiar with. I am officially a volunteer for that group now, and at this convention I helped set up and staff a booth the ASG had to help raise awareness about the ASG and the educational materials available to patients.</span><div><span style="color: #222222;"><br /></span><div><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_PRdnvORyYoLSnJZON2QqOGWdUU50sa54PkAPE2t4HIj-k3k3KQadj-5nilHLy9DqttHFPyDyIcfQybNPjAxM4ERDOZ2Teo7qq9FZXfGwx7WH4KeysJfWGr1inl5GchSIaZVxmcDoY5Fki4EB_70y7X_xFaN4YWt2MWiBxI89-iqTupmaiunUPCYPS8c/s3105/ASH1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="3105" data-original-width="2796" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_PRdnvORyYoLSnJZON2QqOGWdUU50sa54PkAPE2t4HIj-k3k3KQadj-5nilHLy9DqttHFPyDyIcfQybNPjAxM4ERDOZ2Teo7qq9FZXfGwx7WH4KeysJfWGr1inl5GchSIaZVxmcDoY5Fki4EB_70y7X_xFaN4YWt2MWiBxI89-iqTupmaiunUPCYPS8c/w360-h400/ASH1.jpg" width="360" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8gRwuKi-RPc_DZAA0aF2Zrz0hVAhz6gsqaNyYzk7j1deQbgao3x1eNmKECVANJ1NIOZyzR7bU4pMUPE6btzqQGpnGaZB7ssSd4EK_575PKPHU0OMLNyj2ssR2UnvoyY_SkH2PLCLlhK9kJugRHdiiVdOM5BVSsxzZj1z92mT-vtYE36hX1U-AisiFFdo/s2620/ASH2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2620" data-original-width="2484" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8gRwuKi-RPc_DZAA0aF2Zrz0hVAhz6gsqaNyYzk7j1deQbgao3x1eNmKECVANJ1NIOZyzR7bU4pMUPE6btzqQGpnGaZB7ssSd4EK_575PKPHU0OMLNyj2ssR2UnvoyY_SkH2PLCLlhK9kJugRHdiiVdOM5BVSsxzZj1z92mT-vtYE36hX1U-AisiFFdo/w379-h400/ASH2.jpg" width="379" /></a></div><br /><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;"><br /></span></div><div><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;"><br /></span></div><div><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;"><br /></span></div><div><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;">This is a huge convention which usually has over 25,000 medical professionals in attendance from around the world. We had a good turnout at our booth and passed out a lot of the awareness booklets the ASG put together, and I know we had people from at least 12 countries visit and express some sort of interest.</span><br style="color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small;" /><br style="color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small;" /><span face="Arial, Helvetica, sans-serif" style="background-color: white; color: #222222; font-size: small;">So that's a wrap on 2023. We'll see what 2024 has in store for us.</span><br /><br /><br /></div></div>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-30822014746530902282023-01-01T20:20:00.001-05:002023-01-01T20:20:00.173-05:00Happy New Year!!!!!!!!!! !<p><span style="font-family: arial;">Greetings once again, loyal readers of the Fibrinogen Amyloidosis blog. I hope 2023 is going well for you so far.</span></p><p><span style="font-family: arial;">Since this is my eleventh Happy New Year post I have eleven exclamation points in the title. I briefly considered using something like Roman numerals and replacing ten of those exclamation points with the letter "X." But then I realized I didn't want to eliminate exclamation points altogether for years 15 and 20, or force an exclamation point in there somehow, so I decided against that. What I have settled on for now is to put a space after every tenth exclamation point to make them easier to count.</span></p><p><span style="font-family: arial;"><br /></span></p><p><span style="font-family: arial;">I'm still alive and kicking, and asymptomatic at the ripe old age of 60. I do have a little bit of personal health news to report, which I'll do after a quick update on some blog stats.</span></p><p><span style="font-family: arial;"><br /></span></p><p><span style="font-family: arial;">Since this is the third consecutive Happy New Year post, there obviously wasn't much activity on the blog in 2022. This post brings the total number of posts up to 193. The all time pageviews increased from 250K to 282K in 2022.</span></p><p><span style="font-family: arial;">Only one new country visited the blog in 2022, bringing the total to 167. It was Faroe Islands, which is an autonomous territory in the Kingdom of Denmark. It's a group of islands about halfway between Iceland and the coast of Norway, with a population of approximately 54,000.</span></p><p><span style="font-family: arial;"><br /></span></p><p><span style="font-family: arial;">Ok, to bring you up to speed on my health news we need to go back two years, to January of 2021.</span></p><p><span style="font-family: arial;"><br /></span></p><p><span style="font-family: arial;"><b>2021</b></span></p><p><span style="font-family: arial;">January: Annual physical exam. Serum creatinine = 1.11 mg/dL; GFR > 59; Creatinine-spot Urine = 160 mg/dL</span></p><p><span style="font-family: arial;">February: My doctor's office called me and said they would like to refer me to a nephrologist since my creatinine-spot number was a little high, just to be on the safe side since I have fibrinogen amyloidosis. I had not paid much attention to my creatinine-spot numbers before, and if I remember correctly from doing a little research at that time it's not a very useful measurement by itself since it can increase in the short term for a variety of reasons. But it can be an indicator that additional tests and follow-up are warranted. I don't have creatinine-spot numbers in my lab work before 2017, and that year it was 148 mg/dL. In 2018 it was 45, then 39 in 2019.</span></p><p><span style="font-family: arial;">March: On the Ides of March I had two firsts: My first nephrologist appointment and my first virtual doctor appointment. This was about one year into the Covid-19 pandemic so medical facilities were still limiting patient contact as much as possible. The appointment with Dr. S went well and she asked about my genetic testing and Mom's medical history. I could tell she knew this was something other than AL amyloidosis, and she half-jokingly said I probably know more about fibrinogen amyloidosis than she does. She said she would do some basic lab work and go from there, and if everything seemed fine she would monitor my numbers every six months for now, then extend that out. Two days later I had lab work and her office let me know my kidney function was normal. It was a relief to hear that from a nephrologist, although I wasn't overly concerned. (Serum creatinine = 1.19 mg/dL; GFR normal; Creatinine-spot Urine = 106 mg/dL)</span></p><p><span style="font-family: arial;">July: 6 month follow-up lab work by general physician. </span><span style="font-family: arial;">Serum creatinine = 1.01 mg/dL; GFR > 59; Creatinine-spot Urine = 60 mg/dL</span></p><p><span style="font-family: arial;">September: Lab work with the nephrologist again. Kidney function still normal. (Serum creatinine = 1.09 mg/dL; GFR normal; Creatinine-spot Urine = 31 mg/dL)</span></p><p><span style="font-family: arial;"><br /></span></p><p><span style="font-family: arial;"><b>2022</b></span></p><p><span style="font-family: arial;">April: In-person visit with nephrologist. </span><span style="font-family: arial;">Kidney function normal. (Serum creatinine = 1.09 mg/dL; GFR normal; Creatinine-spot Urine = 74 mg/dL)</span></p><p><span style="font-family: arial;">November: Physical exam. Kidney function normal. (</span><span style="font-family: arial;">Serum creatinine = 1.16 mg/dL; GFR > 59; Creatinine-spot Urine = 35 mg/dL) </span></p><p><span style="font-family: arial;"><br /></span></p><p><span style="font-family: arial;">In summary, my kidneys seem to be doing fine and my creatinine-spot urine seems to fluctuate quite a bit. No proteinuria detected, so no 24-hour urine tests. I</span><span style="font-family: arial;">f my kidney function does start to decline it will likely be caught early since I now see a nephrologist periodically, and those appointments are staggered with appointments with my general physician where I also get lab work done.</span></p><p><span style="font-family: arial;"><br /></span></p><p><span style="font-family: arial;">That's all there is to report right now. Until next time, stay healthy and take care.</span></p>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-68034498465982817752022-01-01T22:10:00.000-05:002022-01-01T22:10:03.726-05:00Happy New Year!!!!!!!!!!<p><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">Greetings once again, loyal readers of the Fibrinogen Amyloidosis blog. Long time no see. Since this is my tenth Happy New Year post, I have ten exclamation points in the title of this blog post. When I first mentioned that scheme in the 2014 Happy New Year post, I said, "Hopefully I'll be around long enough such that the number of exclamation points becomes ridiculous." If we aren't there yet, I think we're pretty close.</span></p><p><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;"><br /></span></p><p><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">For those of you who subscribe by email, be sure to read to the end of this post for some important information.</span></p><p><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;"><br /></span></p><p><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">So, what happened with the blog in 2021? Not much, obviously. The post before this one was the Happy New Year post for 2021, so the grand total for 2021 was . . . one post. I was going to start posting some things late in the year, but at some point I decided to just leave 2021 alone and work on making 2022 better. I know I will be doing at least one post in 2022 to cover a bit of personal health news. Nothing serious, but here's a teaser: I have a nephrologist now.</span></p><p><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;"><br /></span></p><p><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">Total all time pageviews for the blog increased from 191K to 250K this year, with pageviews per month ranging from 1100 to 9400. Five new countries visited the blog in 2021, bringing the total to 166. The five new visitors were:</span></p><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">
Myanmar (Burma)
Uzbekistan
Vanuatu
Yemen
Zimbabwe
If you plot those five countries on a world map (Mercator projection) you'll see they form an upside down letter "V," with Uzbekistan at the top.</span><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;"><br /></span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">Spam comments were very sparse once again in 2021. Other than one about Russian call girls, the spam comment with the most practical information was this one: "To make sure you get paid on time, always use an invoice form that contains the right details such as payment terms, itemized charges, and your payment address."</span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;"><br /></span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">As some of you know, the amyloidosis community lost a very important member in 2021. Dr. Merrill Benson of Indiana University School of Medicine passed away on September 11, 2021. He was instrumental in discovering many hereditary amyloidosis mutations, including the first known fibrinogen amyloidosis mutation (Arg554Leu) in 1993, followed by the most common one (Glu526Val) in 1994. I always enjoyed listening to the presentations he gave at the hereditary amyloidosis meetings in Chicago, and he will surely be missed by many colleagues and patients. Here are links to his obituaries published in the Indianapolis Star newspaper and in the most recent issue of the journal Amyloid. The one in Amyloid was written by a colleague of his and covers more details of his career and what it was like to work with him, so be sure to read them both.
</span><a class="contentLink" href="https://www.indystar.com/obituaries/ins126861" rel="noreferrer" style="-webkit-tap-highlight-color: transparent; background: rgb(255, 255, 255); border: 0px; color: #4baddf; cursor: pointer; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline; white-space: pre-wrap;" target="_blank">https://www.indystar.com/obituaries/ins126861</a><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">
</span><a class="contentLink" href="https://www.tandfonline.com/doi/full/10.1080/13506129.2021.1996992" rel="noreferrer" style="-webkit-tap-highlight-color: transparent; background: rgb(255, 255, 255); border: 0px; color: #4baddf; cursor: pointer; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline; white-space: pre-wrap;" target="_blank">https://www.tandfonline.com/doi/full/10.1080/13506129.2021.1996992</a><a class="contentLink" href="https://www.tandfonline.com/doi/full/10.1080/13506129.2021.1996992" rel="noreferrer" style="-webkit-tap-highlight-color: transparent; background: rgb(255, 255, 255); border: 0px; color: #4baddf; cursor: pointer; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline; white-space: pre-wrap;" target="_blank">
</a><a class="contentLink" href="https://www.tandfonline.com/doi/full/10.1080/13506129.2021.1996992" rel="noreferrer" style="-webkit-tap-highlight-color: transparent; background: rgb(255, 255, 255); border: 0px; color: #4baddf; cursor: pointer; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline; white-space: pre-wrap;" target="_blank">
</a><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;"><br /></span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">Ok, here is the news for email subscribers. Since the creation of this blog, subscribing via email was accomplished by a Google service called Feedburner. That service used the email address you entered when you subscribed to the blog and sent an email when a new post was published. Unfortunately, I received notice early in 2021 that Google would no longer support Feedburner. If I understood that notice correctly, existing feeds would still work indefinitely but new subscriptions would be disabled. So I poked around on the internets and found another free service I could use instead of Feedburner, and at some point I removed the Feedburner subscribe widget from the blog and added one for the new service, called Follow.It.</span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;"><br /></span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">Note that I have not moved any subscriptions over from the Feedburner service to the Follow.It </span><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">service because I feel like people should opt in to that only if they want to. So right now, as of January 1, 2022, your Feedburner subscription is still active and if you automatically received an email with this blog post then the service is still working. (I have not tested it, so I honestly do not know yet.) If the bottom of the email has these two lines . . .</span></div><div><a class="contentLink" href="https://www.tandfonline.com/doi/full/10.1080/13506129.2021.1996992" rel="noreferrer" style="-webkit-tap-highlight-color: transparent; background: rgb(255, 255, 255); border: 0px; color: #4baddf; cursor: pointer; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline; white-space: pre-wrap;" target="_blank">
</a><i><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">You are subscribed to email updates from Fibrinogen Amyloidosis. </span><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">
To stop receiving these emails, you may unsubscribe now. </span><a class="contentLink" href="https://www.tandfonline.com/doi/full/10.1080/13506129.2021.1996992" rel="noreferrer" style="-webkit-tap-highlight-color: transparent; background: rgb(255, 255, 255); border: 0px; color: #4baddf; cursor: pointer; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline; white-space: pre-wrap;" target="_blank">
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</a><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">. . . then that email came from Feedburner, in which case you do not have to do anything to keep receiving the blog posts via email from that service. (Again, "they" say it will continue working indefinitely, which doesn't necessarily mean forever.)</span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;"><br /></span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">But if you did receive the email from Feedburner and would like to switch to the new service (Follow.It)</span><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">, just visit the blog (</span><a class="contentLink" href="http://www.fibrinogenamyloidosis.com/" rel="noreferrer" style="-webkit-tap-highlight-color: transparent; background: rgb(255, 255, 255); border: 0px; color: #4baddf; cursor: pointer; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline; white-space: pre-wrap;" target="_blank">www.fibrinogenamyloidosis.com</a><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">) and click the Subscribe button on the right side of the page after entering your email address. You will get a pop-up message asking you to click the confirmation link in the email it just sent you. That email will also tell you how to log in to the Follow.It</span><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;"> web site to manage your subscription. Once you receive a blog post from the Follow.It </span><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">service you can unsubscribe from the Feedburner service using the link at the bottom of that email.</span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;"><br /></span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">If you did not receive this blog post via email but would like to subscribe, click the Subscribe button on the right side of the page after entering your email address.</span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;"><br /></span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">In summary, if you received this blog post via email you do not have to do anything to continue receiving them via email. If you did not receive this blog post via email and would like to receive future blog posts, click the Subscribe button on the right side.</span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;"><br /></span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">I know that was a lot to follow, so there will probably be some more communication about it either in additional blog posts, comments on this post, or both. If you have any questions or need help with your email subscriptions, feel free to email me directly at toe at juno dot com. Hopefully we can get everything straightened out by the end of the year.</span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;"><br /></span></div><div><span style="background-color: white; color: #868c90; font-family: -apple-system, "system-ui", "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 13px; white-space: pre-wrap;">David</span></div>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-73377757636829760742021-01-31T10:33:00.001-05:002021-05-11T06:36:00.683-04:00Happy New Year!!!!!!!!!<span style="font-family: arial;">Greetings, loyal readers of the Fibrinogen Amyloidosis blog. Welcome to 2021, which has to be an improvement compared to 2020, right?<br /><br /><b>Here is what happened with the blog in 2020:</b><br /><br /><ul style="text-align: left;"><li><span style="font-family: arial;">2 new blog posts were written. (Down from 3 in 2019)</span></li><li><span style="font-family: arial;">No new articles were reviewed.</span></li><li><span style="font-family: arial;">2 additional countries visited the blog, bringing the total to 161.</span></li></ul><br /><br />In patient news, I became aware of two more families affected by fibrinogen amyloidosis in 2020, and I know of one combined liver and kidney transplant that occurred in the US. As for me, I am still asymptomatic. My creatinine was just barely above the normal range in July of 2020 but then back in the normal range again when it was checked in January of 2021. There is still no indication of protein in the urine and my eGFR is fine, so for now I'll consider the high creatinine reading to be an anomaly.<br /><br />Hopefully I can catch up on some article reviews this year. (It seems like I've said that before). There have been a few articles published in the past couple of years specifically about fibrinogen amyloidosis, although at a glance they do not seem to have any significant developments with regard to treatment.<br /><br />One of the benefits of fewer blog posts is that it reduces the number of spam comments, as the blog only received two this year. Neither one was particularly entertaining like some previous spam comments have been, but one got my attention when I was reviewing them for this blog post. Here is the comment (edited for typos), minus the hyperlink which is the usual tipoff that a comment is spam: "You have done a great job. I hope you will do much better in the future." Me too, spammer. Me too.<br /><br /><br />=====Consolidated blog stats for second half of 2020=====<br /><br />As of December 31, 2020:<br /><br />Total posts: 190<br /><br />Total pageviews: 191K (significantly impacted by heavy daily traffic from Hong Kong until December)<br /><br />Email subscribers: 15 (unchanged)<br /><br />Total number of countries that have viewed the blog: 161<br /><br />No new countries viewed the blog in the second half of 2020.<br />=====</span><br />Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com04595 Poplar Tent Rd, Concord, NC 28027, USA35.4142351 -80.654281335.40024501229361 -80.6714474376953 35.428225187706389 -80.637115162304681tag:blogger.com,1999:blog-4284577738924004196.post-42277115519791438392020-07-30T22:13:00.000-04:002020-07-30T22:13:56.768-04:00Ten years?<div style="text-align: justify;"><span style="font-family: arial;">Greetings, loyal fibrinogen amyloidosis blog readers! If you are reading this email or blog entry during the summer of 2020 I hope you are staying safe and COVID free. For those of you reading this on the blog many years after 2020, I hope the COVID pandemic of 2020 is finally over and you no longer have to view every person you get close to as potentially hazardous to your health. (Also, you citizens of the future should always have plenty of toilet paper at home. Trust me.) </span></div><div style="text-align: justify;"><span style="font-family: arial;"><br /></span></div><div style="text-align: justify;"><span style="font-family: arial;">There is not much news to report from here. I am still asymptomatic, and my only recent medical issue was a little scare with some chest pain that my doctor and I are attributing to musculoskeletal stress while playing around with my grandson in the front yard one afternoon. (If playing with a six-year-old child sends you to the emergency room, does that mean you're getting old?) One benefit of this episode is that I had a stress test and echocardiogram, both of which were normal. So now I have some baseline measurements in case things start to change later.</span></div><div style="text-align: justify;"><span style="font-family: arial;"><br /></span></div><div style="text-align: justify;"><span style="font-family: arial;">Although I still do not have an article review ready for the blog, I wanted to get a post out today, July 30, 2020, because it was ten years ago today when Mom and I were informed by Dr. Martha Skinner of the Boston University Amyloidosis Center that genetic testing showed Mom had the fibrinogen mutation. Here's a link to my blog post where I described that call and what happened over the next few days:</span></div><div style="text-align: justify;"><span style="font-family: arial;"><a href="http://www.fibrinogenamyloidosis.com/2012/10/july-30-2010-genetic-testing-results.html">http://www.fibrinogenamyloidosis.com/2012/10/july-30-2010-genetic-testing-results.html</a></span></div><div style="text-align: justify;"><span style="font-family: arial;"><br /></span></div><div style="text-align: justify;"><span style="font-family: arial;">That was the beginning of my journey into the world of fibrinogen amyloidosis, and it has certainly been an interesting ten years. That first article Dr. Skinner sent me has now grown to around 60, most of which have been reviewed on the blog. It is also worth noting that the current treatment options for fibrinogen amyloidosis are essentially the same as what Dr. Skinner told us over the phone in 2010, which is organ transplants. Hopefully that will not still be true in 2030.</span></div><div style="text-align: justify;"><span style="font-family: arial;"><br /></span></div><div style="text-align: justify;"><span style="font-family: arial;">I will go ahead and close out this post by once again saying I hope to start doing some article reviews soon. But I am not going to suggest that will happen once things calm down in the world. So goodbye for now, stay safe, and carry on.</span></div><div><span style="font-family: arial;"><br /></span></div><div><span style="font-family: arial;">= = = = =</span></div><div><span style="font-family: arial;">Combined stats for January through June</span></div><div><span style="font-family: arial;"><br /></span></div><div><span style="font-family: arial;">Total posts: 189 (1 in January)</span></div><div><span style="font-family: arial;"><br /></span></div><div><span style="font-family: arial;">Total pageviews: 152K (average 2K per month)</span></div><div><span style="font-family: arial;"><br /></span></div><div><span style="font-family: arial;">Email subscribers: 15 (unchanged)</span></div><div><span style="font-family: arial;"><br /></span></div><div><span style="font-family: arial;">Total number of countries that have viewed the blog: 161</span></div><div><span style="font-family: arial;"><br /></span></div><div><span style="font-family: arial;">New countries:</span></div><div><span style="font-family: arial;"><a href="https://en.wikipedia.org/wiki/Palau">Palau</a></span></div><div><span style="font-family: arial;"><a data-original-attrs="{"data-original-href":"https://en.wikipedia.org/wiki/Kosovo"}" href="#" target="_blank">Kosovo</a></span></div><div><span style="font-family: arial;">= = = = =</span><br /></div>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-61298059249783245522020-01-16T11:00:00.000-05:002020-01-16T11:00:07.647-05:00Happy New Year!!!!!!!!<span style="font-family: "arial" , "helvetica" , sans-serif;">Welcome to 2020 everyone. In keeping with my tradition, there are eight exclamation points in the title (or subject line) since this is my eighth Happy New Year post in the history of this blog.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Here is what happened with the blog in 2019:</b></span></div>
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<ul>
<li><span style="font-family: "arial" , "helvetica" , sans-serif;">3 new blog posts were written. (Down from 4 in 2018)</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">No new articles were reviewed.</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">9 additional countries visited the blog, bringing the total to 159.</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">The blog received 14 spam comments in 2019. None were especially noteworthy, but if I had to choose a favorite it would be the one that began with this: "Hi! Someone in my Myspace group shared this website with us so I came to take a look."</span></li>
</ul>
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<span style="font-family: arial, helvetica, sans-serif;">In patient news, I believe I became aware of two more families affected by fibrinogen amyloidosis in 2019, and I know of one combined liver and kidney transplant that occurred in 2019 and another that almost occurred but was cancelled at the last minute. In personal news, I am still asymptomatic.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">That's about it for 2019. I hope you all have a safe and healthy 2020.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br />=====Monthly Blog Status Update=====</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br />As of December 31, 2019:<br /><br />Total posts: 188 (1 in December)<br /><br />Total pageviews: 139K (~2000 in December)<br /><br />Email subscribers: 15 (down by 1)<br /><br />Total number of countries that have viewed the blog: 159<br /><br />No new countries viewed the blog in December.<br />=====</span></div>
Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-80726661682020007052019-12-09T11:22:00.002-05:002021-07-17T15:42:57.509-04:002019 Hereditary Amyloidosis Support Group Meeting<h4>
<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">Hello, fellow fibrinogen amyloidosis patients. Today's post will be my overdue (and surprisingly lengthy) recap of the 2019 Hereditary Amyloidosis Support Group Meeting that was held in Chicago the last weekend of October. But before I start that I want to mention that two fibrinogen amyloidosis patients recently underwent combined liver and kidney transplants, one in Brazil and one in the US. We wish these patients the best in their recovery as they join the very small population of people cured of amyloidosis. [Edit: The one in the US did not actually occur because the potential donor liver was not a good enough match.]</span></span><br />
<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">We will begin with my travel to the meeting. Since I was traveling alone this year I decided to arrive on Friday instead of a day or two early to visit Chicago. You longtime blog followers may recall that it is not unusual for something out of the ordinary to happen to me while traveling to or from these Chicago meetings. (For 2011, see here (<a href="http://www.fibrinogenamyloidosis.com/2012/11/october-2011-familial-amyloidosis.html" target="_blank">http://www.fibrinogenamyloidosis.com/2012/11/october-2011-familial-amyloidosis.html</a>) and for 2013, see here (<a href="http://www.fibrinogenamyloidosis.com/2013/10/getting-to-2013-familial-support-group.html" target="_blank">http://www.fibrinogenamyloidosis.com/2013/10/getting-to-2013-familial-support-group.html</a>). This trip's noteworthy travel moment occurred when I was standing in the security line at the airport Friday morning and realized I did not have a photo ID with me. Nope, I had scanned my driver license for something the day before and I left it on our scanner at home. Totally my fault. Panic set in. Can my wife get my ID to me in time? If I miss this flight, when is the next one?</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">Fortunately I learned from an agent at the American Airlines ticket counter that it is possible to get through TSA security without a photo ID if you are willing and able to do something called a secondary screening. First you have to present some things with your name on them, such as credit cards and insurance cards. If you make it through that they closely inspect everything you are carrying on, and then they closely inspect you. And I mean this is a very close inspection, probably more thorough than a police pat down. (Fortunately I have never had a police pat down so I do not have anything to compare it to.) The lesson learned is if you do not want a stranger touching you in places only your spouse or doctor usually touches you, be sure to bring your ID to the airport.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">I got through security in plenty of time to catch my flight to Chicago, thankful I was not renting a car but wondering if I could check into my hotel without a photo ID. Fortunately I had a picture of my driver license on my phone, so no strip search or pat down was required to check in.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">Once I got to my room I looked over the packet of material for meeting attendees that the Amyloidosis Support Groups assembled for the hotel to distribute when people checked in. In addition to the meeting agenda and a list of presenters and other medical personnel in attendance, I was saddened to see a page informing us that Dr. Steven Zeldenrust of the Mayo Clinic had passed away in July after a 10-year battle with cancer. I remembered him from the first two Chicago meetings I attended (2011 and 2013), and he was an author on over 100 articles related to amyloidosis, including two articles I have reviewed on this blog regarding organ transplantation. He was 56 years old.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">Since it was still a few hours before the Friday evening Meet and Greet I went downstairs to make sure I knew where the rooms were for the meeting. Here are some pictures of the meeting room after it was set up late in the day on Friday. Compared to the ballroom at the O'Hare Hilton that was used for the 2015 and 2017 meetings, this room was much wider but not as deep front-to-back.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">At the Meet and Greet I talked with a few other patients, all with hereditary ATTR, as well as someone from <a href="http://oneamyloidosisvoice.com/" target="_blank">OneAmyloidosisVoice.com</a>. I also met with Mackenzie Boedicker of Mackenzie's Mission (<a href="https://mm713.org/" target="_blank">https://mm713.org/</a>) and her mother Deb Boedicker, also of Mackenzie's Mission and the Amyloidosis Speakers Bureau (<a href="https://mm713.org/speakers-bureau/" target="_blank">https://mm713.org/speakers-bureau/</a>). The speakers bureau is doing some amazing work to increase the awareness of amyloidosis among the next generation of doctors, and I am excited to be one of the scheduled speakers in March at a medical school in Chicago.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">The agenda for the meeting on Saturday was very similar to that of previous meetings, with some notable additions. PDF files of all of the presentations are available at this link: <a href="http://amyloidosissupport.org/support_groups/familial.html" target="_blank">http://amyloidosissupport.org/support_groups/familial.html</a>. Also at that same link is a 60 page PDF file (NOTES AND SOME Q AND A FROM THE MEETING) with notes taken by someone associated with Amyloidosis Support Groups. I have only glanced at a few pages of that document and it appears to be very well done, with summaries, bullet points, charts and other graphics. The direct link to that PDF file is: <a href="http://amyloidosissupport.org/support_groups/2019_notes.pdf" target="_blank">http://amyloidosissupport.org/support_groups/2019_notes.pdf</a>.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">Here is what the meeting room looked like Saturday morning:</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">The one presentation that dealt specifically with fibrinogen amyloidosis was the one on solid organ transplantation by Dr. Dispenzieri. The direct link to the PDF of her presentation is here: <a href="http://amyloidosissupport.org/support_groups/2019_06_dispenzieri.pdf" target="_blank">http://amyloidosissupport.org/support_groups/2019_06_dispenzieri.pdf</a>. (Since these are PDF files on the ASG web site and not PowerPoint presentations, you don't always see the slides as they were presented due to overlapping graphic elements.)</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">Dr. Dispenzieri began with some information about organ transplants for patients with ATTR, since it is by far the most common type of hereditary amyloidosis. One piece of information I do not recall hearing before is that many patients who receive a liver from an ATTR patient as part of a domino liver transplant are developing symptoms of ATTR about ten years after the transplant. This was not expected because ATTR symptoms typically occur late in life, so the assumption was that a liver from an ATTR patient transplanted into a non-ATTR patient would take several decades before ATTR symptoms would appear.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">She then talked about organ transplants for fibrinogen amyloidosis patients. She stressed that a kidney transplant without a liver transplant would likely fail within 1 to 7 years, and the 10-year survival rate for kidney transplants was 5%. That bullet point on the slide presentation says "5% (vs 65%)," but it does not say exactly what the 65% number is referring to. I assume that is for combined liver and kidney transplants. She then mentioned that a liver only transplant was a relatively new treatment option for AFib patients, and as you can see in the presentation she showed the chart from a Letter to the Editor in the 2016 issue of the journal Amyloid, which I reviewed in the May 1, 2016 blog post here: </span><span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="http://www.fibrinogenamyloidosis.com/2016/04/article-review-2016-liver-transplant.html" target="_blank">http://www.fibrinogenamyloidosis.com/2016/04/article-review-2016-liver-transplant.html</a>. This chart plots the creatinine level of the first AFib patient to have a liver only transplant, starting at about a year before transplant through five years after the transplant, and clearly shows a long term, gradual improvement in the creatinine level. She did not mention how many liver only transplants have been done for AFib, but I am aware of three.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">The presentation by the genetic counselor was informative as always, although she was pressed for time and had to rush through or skip some things, which was true of most of the presentations. I did learn about something new with regard to genetic testing during this meeting, though, that was mentioned elsewhere. For couples thinking of becoming pregnant and using in vitro fertilization (IVF), there is a procedure called preimplantation genetic diagnosis which can be used prior to implantation to help identify genetic defects within embryos. I won't discuss the pros and cons and other considerations of that procedure, but here is a link if you would like more information about it: <a href="https://americanpregnancy.org/getting-pregnant/preimplantation-genetic-diagnosis/" target="_blank">https://americanpregnancy.org/getting-pregnant/preimplantation-genetic-diagnosis/</a>.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">The next presentation that got my attention and I feel is important for everyone was by Bob Gibson of Amyloidosis Support Groups. He discussed the Amyloidosis Patient Registry, which I remember being mentioned at the 2015 meeting. (<a href="http://www.amyloidosissupport.org/registry/index.html" target="_blank">http://www.amyloidosissupport.org/registry/index.html</a>) Copying from the first paragraph of the web site:</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><i>"The Amyloidosis Patient Registry is a new resource for the entire amyloidosis community from Amyloidosis Support Groups. By compiling data on patient experiences with amyloidosis, the Registry will become the go-to resource for medical researchers and caregivers in their pursuit of earlier diagnosis, better treatment, and improved quality of life for those affected by this debilitating disease."</i></span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">The registry is essentially a database of information gathered from amyloidosis patients about their symptoms, path to diagnosis, treatment, quality of life, etc. They were very concerned about privacy when developing this, so they partnered with a company called PrivateAccess that has experience in creating such things and keeping the information as private as the user desires. I registered for it on my phone and started answering the survey questions while Bob was speaking about it. I found it very easy to make the choices regarding what information could be shared with any researchers with access to the database vs. what information could only be shared with my permission. I would encourage anyone who has a confirmed diagnosis of amyloidosis or a confirmed mutation but is still asymptomatic to enter their information into the registry. I have since learned that it works better on a laptop or desktop computer than it does on phone.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">One of the new topics at this year's meeting was Practical Help and Assistive Devices, presented by Sarah Boyd of Mayo Clinic. Her presentation is available here: <a href="http://amyloidosissupport.org/support_groups/2019_15_boyd.pdf" target="_blank">http://amyloidosissupport.org/support_groups/2019_15_boyd.pdf</a>. She discussed the role of occupational therapists, who are "specialists aiming to improve and restore your ability to perform daily activities within the home, hobbies, or job through restorative training or compensatory training using adaptive equipment." There was a lot of good information in her presentation regarding the kinds of help we all may need at some point in our lives, not just as a result of amyloidosis.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">Another new topic that I believe everyone found interesting, even though it was late in the day and was one of the longer presentations, was on insurance and financial assistance presented by a cancer rights attorney. I will not cover her presentation here since there was so much and I cannot do it justice, but I do recommend reviewing the previously mentioned notes from the meeting (link to: <a href="http://amyloidosissupport.org/support_groups/2019_notes.pdf" target="_blank">http://amyloidosissupport.org/support_groups/2019_notes.pdf</a>) and also reviewing the information at these two web sites: <a href="https://triagecancer.org/cancer-health-insurance-finances-cost" target="_blank">https://triagecancer.org/cancer-health-insurance-finances-cost</a> and <a href="http://cancerfinances.org/" target="_blank">http://cancerfinances.org/</a> One important point from that presentation I wrote down in my notes was the fact that 60% of all insurance appeals are ruled in favor of patients.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">There was a section on the agenda to discuss current clinical trials, most of which are for patients with hATTR or wild type TTR amyloidosis. Dr. Berk did speak briefly about the doxycycline trail, which was open to fibrinogen amyloidosis patients. The first thing he said was that the jury was still out regarding the effectiveness of doxycycline, then he discussed the issues with the clinical trial conducted by Boston University. A significant percentage of participants had to quit the trial early, many due to becoming hypersensitive to sunlight beyond just a bad sunburn. He believes, in hindsight, there were some issues with the way the study was set up, so there may be more doxycycline trials.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">Before dinner Saturday night there were breakout sessions where patients could visit any of five different rooms for smaller group discussions with specialists devoted to five different topics: Cardiac; Neuropathy and GI; Genetic Counseling and non-TTR hereditary; Insurance questions and Issues; and Research, Treatment and Trials. I started in the Genetic Counseling room since that is one of my favorite topics. There was some good discussion there, but the only new thing I learned and took notes on was pre-implantation genetic diagnosis, which I mentioned earlier in this blog post.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">The other breakout session I visited was the one on Research, Treatment, and Trials. One of the presentations earlier in the day was by Dr. Jonathan Wall of the University of Tennessee regarding a new imaging technique for amyloid he and his team are working on, which uses a synthetic peptide. This imaging technique would be similar in many ways to the SAP scan currently available from the NAC in London, but with some improvements as well. They are still in Phase 1 clinical trials with this scan, and during his presentation Dr. Wall mentioned a future goal would likely be to start imaging some hereditary amyloidosis patients who are known to have tested positive for a mutation but are still asymptomatic. Since I am in that category and live within driving distance of the University of Tennessee I wanted to talk to Dr. Wall about it. He gave me a pamphlet about the program (<a href="http://gsm.utmck.edu/research/ACTP/main.cfm" target="_blank">http://gsm.utmck.edu/research/ACTP/main.cfm</a>) and suggested I send him my contact information so he will have it if and when I might be a candidate for imaging.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">As luck would have it, initial results of this imaging study were presented at this month's ASH Annual Meeting (ASH = American Society of Hematologists). Here's a link to the abstract that was presented: <a href="https://ash.confex.com/ash/2019/webprogram/Paper128850.html" target="_blank">https://ash.confex.com/ash/2019/webprogram/Paper128850.html</a> and here is a link to an article about it at BusinessWire dot com: <a href="https://www.businesswire.com/news/home/20191208005058/en/Aurora-Bio-Announces-Clinical-Data-Lead-Program" target="_blank">https://www.businesswire.com/news/home/20191208005058/en/Aurora-Bio-Announces-Clinical-Data-Lead-Program</a>.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">Sunday was the usual Question and Answer session with the panel of doctors answering questions submitted by the attendees. As you can imagine, these covered a wide range of topics. A summary of the questions and answers can be found toward the end of the previously mentioned notes document from the meeting: <a href="http://amyloidosissupport.org/support_groups/2019_notes.pdf" target="_blank">http://amyloidosissupport.org/support_groups/2019_notes.pdf</a>. I did not submit any questions this time and actually left shortly before it was over so I could try to catch an earlier flight home. Unfortunately I was not able to catch an earlier flight due to the type of ticket I had purchased, so I had plenty of time to walk around the Chicago airport. During that time I learned the distance around entire perimeter of the publicly accessible area of Chicago's O'Hare Airport is just under 10 kilometers and can be walked in two hours.</span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">That is all for now, so if nothing exciting happens the rest of December my next post will be the annual Happy New Year post in January. </span></span><br />
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<span style="font-weight: normal;"><span style="font-family: "arial" , "helvetica" , sans-serif;">==</span><span style="font-family: "arial" , "helvetica" , sans-serif;">===Monthly Blog Status Updates=====</span></span></h4>
<span style="font-family: "arial" , "helvetica" , sans-serif;">As of September 30, 2019:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total posts: 187 (1 in September)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total pageviews: 132K (~1300 in September)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Email subscribers: 16 (unchanged)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total number of countries that have viewed the blog: 157</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">One new country viewed the blog in September:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Saint_Vincent_and_the_Grenadines" target="_blank">St. Vincent & Grenadines</a></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">==========</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">As of October 31, 2019:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total posts: 187 (0 in October)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total pageviews: 133K (~1700 in October)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Email subscribers: 16 (unchanged)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total number of countries that have viewed the blog: 157</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">No new countries viewed the blog in October.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">==========</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">As of November 30, 2019:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total posts: 187 (0 in November)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total pageviews: 137K (~3500 in October)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Email subscribers: 16 (unchanged)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total number of countries that have viewed the blog: 159</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Two new countries viewed the blog in November:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Laos" target="_blank">Laos</a></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Caribbean_Netherlands" target="_blank">Caribbean Netherlands</a></span><br />
=====Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-46201514942361573392019-09-27T09:00:00.000-04:002019-09-27T09:00:01.410-04:00Where has the year gone?<span style="font-family: "arial" , "helvetica" , sans-serif;">Greetings, loyal Fibrinogen Amyloidosis blog readers. I am still here, and I have all kinds of excuses for putting the blog on the back burner since January. They aren't great excuses and most of the major events are over, so we'll see if I can pick up the pace a little going forward. There have been a few recent journal articles related to fibrinogen amyloidosis that I need to review, so hopefully I can get one or two of those done by the end of the year.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">First I should mention that the 2019 Biennial Hereditary Amyloidosis support meeting is less than a month away. It takes place at the O'Hare Hilton in Chicago and starts with a meet and greet the evening of Friday, October 25. More information can be found at this link: </span><span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="http://amyloidosissupport.org/support_groups/familial.html" target="_blank">http://amyloidosissupport.org/support_groups/familial.html</a>. If you plan on coming to the meeting, please send me an email (toe at juno dot com) so we can get together at some point. This will be my fifth such meeting to attend, and you can read my blog posts about previous meetings <a href="http://www.fibrinogenamyloidosis.com/2012/11/october-2011-familial-amyloidosis.html" target="_blank">here</a>, <a href="http://www.fibrinogenamyloidosis.com/2013/10/getting-to-2013-familial-support-group.html" target="_blank">here</a>, <a href="http://www.fibrinogenamyloidosis.com/2015/11/2015-familial-support-group-meeting.html" target="_blank">here</a> and <a href="http://www.fibrinogenamyloidosis.com/2017/11/2017-hereditary-amyloidosis-meeting.html" target="_blank">here</a>.</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">I have updated the <a href="http://www.fibrinogenamyloidosis.com/p/what-to-do-what-to-do.html" target="_blank">What should I do now?</a> page of the blog for the first time since 2013. Other than some minor edits here and there, I did expand on the sections where organ transplants are mentioned. That topic is probably worthy of one or more blog posts.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">A new online amyloidosis community has recently been created as a resource for people diagnosed with amyloidosis and those in the process of being diagnosed. The web site is <a href="https://www.oneamyloidosisvoice.com/" target="_blank">https://www.oneamyloidosisvoice.com/</a>. It has not only a chat feature (called a Social Wall) for people to have discussions (similar to Facebook groups but with many additional features), it also has an ever-growing list of trusted resources that have been approved by medical professionals, plus a section called Diagnosis Educator with information regarding symptoms, medical tests used in diagnosis, and treatment options. This site is still rather new and there is not a lot of activity yet, and although most of the content will be related to AL or ATTR amyloidosis, I would still encourage everyone to take a look at it and join if you feel so inclined. If you explore the community a little you may even find a picture of me and a short bio, as I have some involvement with the ongoing development of the site.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Speaking of the amyloidosis community, our little fibrinogen amyloidosis community continues to grow outside of the US and Europe. Earlier this year I became aware of a large kindred in New Zealand with several family members diagnosed with fibrinogen amyloidosis, and another kindred in Brazil.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In organ transplant news I don't have any news, other than the fact that all the recent transplant recipients I am aware of are doing well, including the third liver-only recipient who received a liver transplant in December of 2018.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In personal health news, I had a physical exam in September and I am still asymptomatic, with normal creatinine and GFR, and no signs of proteinuria.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">That's all for now. I will definitely be blogging about the Chicago meeting, so you won't have to wait another . . . (counting) . . . 8 months for the next post.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update (consolidated) for January through August, 2019=====</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">As of August 31, 2019:</span><br />
<br style="font-family: arial, helvetica, sans-serif;" />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Total posts: 186 (1 in January)</span><br />
<br style="font-family: arial, helvetica, sans-serif;" />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Total pageviews: 130K (~2400 per month, which includes 4500 hits from Israel in one day, and 2000 hits from Israel on another day)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Email subscribers: 16 (increased by 1 in January)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total number of countries that have viewed the blog: 156</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">6 new countries viewed the blog from January through August:</span><br />
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<a href="https://en.wikipedia.org/wiki/Saint_Lucia" style="font-family: arial, helvetica, sans-serif;" target="_blank">St. Lucia</a><br />
<a href="https://en.wikipedia.org/wiki/Cayman_Islands" style="font-family: arial, helvetica, sans-serif;" target="_blank">Cayman Islands</a><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/R%C3%A9union" target="_blank">Reunion</a></span><br />
<a href="https://en.wikipedia.org/wiki/North_Macedonia" style="font-family: arial, helvetica, sans-serif;" target="_blank">North Macedonia</a><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Antigua_and_Barbuda" target="_blank">Antigua and Barbuda</a></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Guatemala" target="_blank">Guatemala</a></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;">=====</span><br />
<br />Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-80879385386915815282019-01-29T12:00:00.000-05:002019-01-29T12:00:11.370-05:00Happy New Year!!!!!!!<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;"><span style="color: black; font-size: small;">Welcome to 2019 everyone. In keeping with my tradition, there are seven exclamation points in the title (or subject line) since this is my seventh Happy New Year post in the history of this blog.</span></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Here is what happened with the blog in 2018:</span></div>
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<ul>
<li><span style="font-family: "arial" , "helvetica" , sans-serif;">4 new blog posts were written. (Down from 8 in 2017)</span></li>
</ul>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">Two new articles were reviewed.</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">5 additional countries visited the blog, bringing the total to 150.</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">The blog surpassed 100,000 all-time views in October.</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">The blog received 21 spam comments in 2018. The most interesting one mentioned Puerto Rican professional boxer Jose Pedraza, Spanish Formula One race car driver Fernando Alonso, and three national wildlife parks in India. It did all that in just three sentences.</span></li>
</ul>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In patient news, I know of one patient who had a combined liver and kidney transplant in 2018, and as I mentioned in the previous blog post, the third liver-only transplant for fibrinogen amyloidosis occurred in December. The use of liver-only transplants for fibrinogen amyloidosis is being covered more in the medical literature now, so that is good news. Speaking of good news, </span><span style="font-family: "arial" , "helvetica" , sans-serif;">I continue to get my annual physical exam and I am still asymptomatic.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">That's about it for 2018. I hope you all have a safe and healthy 2019.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">As of December 31, 2018:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total posts: 185 (1 in December)</span><br />
<br style="font-family: arial, helvetica, sans-serif;" />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Total pageviews: 110K (~2800 in December)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Email subscribers: 15 (unchanged)</span><br />
<br style="font-family: arial, helvetica, sans-serif;" />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Total number of countries that have viewed the blog: 150</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">No new countries viewed the blog in December.</span><br />
=====Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-30684138344847073052018-12-30T22:20:00.000-05:002018-12-30T22:20:03.388-05:00And then there were three<span style="font-family: "arial" , "helvetica" , sans-serif;">Happy Holidays, loyal blog readers. Hopefully you are all enjoying or recovering from the holidays.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">This post was prompted not only by the fact that time is running out for me to average one post per quarter this year, but also by something exciting that recently occurred in the world of fibrinogen amyloidosis. Naturally I will cover a few less exciting things first, and save the best for last.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">First, please be aware that registration is now open for the sixth Hereditary Amyloidosis Support Group Meeting that occurs every two years in Chicago. The dates for the 2019 meeting are Friday, October 25 through Sunday, October 27. Friday night is a dinner and meet-and-greet, Saturday is a full day of presentations by the doctors, and Sunday morning is a question and answer session where the doctors answer questions submitted by the attendees. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The meeting will be held at the Hilton Chicago O'Hare Airport, which is very convenient because if you fly into O'Hare you can walk to the Hilton without even going outside. Links to register for the meeting (which is free) and to get the hotel group rate are here:</span><br />
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<a href="http://amyloidosissupport.org/support_groups/familial.html" style="font-family: arial, helvetica, sans-serif;" target="_blank">http://amyloidosissupport.org/support_groups/familial.html</a><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">This meeting is a great opportunity to see presentations by and mingle with some of the most knowledgeable amyloidosis doctors in the world. Although the bulk of the meeting is geared toward patients with ATTR amyloidosis (hereditary or wild type), I still find it worthwhile to attend for several reasons, not the least of which is being able to meet other patients with the same disease. H</span><span style="font-family: "arial" , "helvetica" , sans-serif;">ere are links to my blog entries about the previous four meetings I attended:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">2011: <a href="http://www.fibrinogenamyloidosis.com/2012/11/october-2011-familial-amyloidosis.html" target="_blank">http://www.fibrinogenamyloidosis.com/2012/11/october-2011-familial-amyloidosis.html</a></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">2013: <a href="http://www.fibrinogenamyloidosis.com/2013/10/getting-to-2013-familial-support-group.html" target="_blank">http://www.fibrinogenamyloidosis.com/2013/10/getting-to-2013-familial-support-group.html</a></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">2015: <a href="http://www.fibrinogenamyloidosis.com/2015/11/2015-familial-support-group-meeting.html" target="_blank">http://www.fibrinogenamyloidosis.com/2015/11/2015-familial-support-group-meeting.html</a></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">2017: <a href="http://www.fibrinogenamyloidosis.com/2017/11/2017-hereditary-amyloidosis-meeting.html" target="_blank">http://www.fibrinogenamyloidosis.com/2017/11/2017-hereditary-amyloidosis-meeting.html</a></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In other less exciting yet good news, I had some lab work done in September and I am still asymptomatic. My creatinine was 1.05 mg/dL and my estimated GFR was over 59. I am about ten years younger than my mother was when her first symptoms appeared, so I will probably be in wait-and-see mode for many years to come, hopefully forever.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In November I attended the local amyloidosis support group meeting in Charlotte, North Carolina. There were about 25 people in attendance, including patients, caregivers, and doctors. Although I know I am likely to be the only fibrinogen amyloidosis patient at these local support group meetings and most of the topics discussed will not apply to me, I still enjoy going to them because I always find it interesting listening to the doctors and hearing the stories of other patients.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">One of the doctors at the November meeting gave what I thought was a very good answer to a question someone asked about kidneys healing. The question was about how well the kidneys recover after amyloid production in the body is stopped. We know different organs respond differently to not only the buildup of amyloid deposits but also to the removal of amyloid deposits. When the kidneys are damaged (scarred) by amyloid deposits, can they recover once amyloid production stops and the amyloid deposits are cleared, or are they scarred and therefore damaged for life? The doctor gave this analogy: Imagine a multi-lane highway where traffic is flowing smoothly and the roads are in good condition. That represents your kidneys functioning normally, without amyloid buildup. Now imagine a large boulder landing on this highway and not only blocking traffic in one or more lanes but also damaging the road. Think of that boulder as amyloid deposits and the reduced traffic flow as reduced kidney function. As long as that boulder is sitting on the highway, traffic flow is going to be reduced. But what happens when the boulder is removed? That will likely allow some improved traffic flow through the areas of the road that were not as badly damaged by the boulder, but some areas are so badly damaged that traffic flow through them will not get back to normal for a long time, if ever. And so it is with the kidneys. Kidney function will usually improve somewhat and then stabilize at some point after amyloid production is stopped (perhaps with continued very slow improvement), but it typically never returns to normal because some parts will never heal.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Speaking of kidneys, there was an interesting abstract presented in October of 2018 at ASN Kidney Week, an annual gathering of kidney professionals from around the globe </span><span style="font-family: "arial" , "helvetica" , sans-serif;">put together by the American Society of Nephrology. The title of this abstract was "Role of Liver Transplantation in the Treatment of Fibrinogen A alpha-chain Amyloidosis." Here is a link to the abstract:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://www.asn-online.org/education/kidneyweek/2018/program-abstract.aspx?controlId=3020418" target="_blank">https://www.asn-online.org/education/kidneyweek/2018/program-abstract.aspx?controlId=3020418</a></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The abstract is not long at all, so I highly recommend reading the whole thing. It presents a case for considering liver transplantation curative for fibrinogen amyloidosis. After stating that isolated kidney transplants in AFib patients typically fail due to recurrent amyloid within 1 to 5 years, it presents data on 13 patients who received liver-kidney transplants and two who received only liver transplants. The data shows there is an obvious benefit to liver transplantation, especially for those patients who have not started dialysis. Here is the conclusion of the abstract:</span><br />
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<blockquote class="tr_bq">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><i>The therapeutic potential of liver transplantation in fibrinogen amyloidosis is truly curative. Best transplant benefit from the addition of liver to kidney grafts was achieved in low risk pre-dialysis patients. Timely intervention in the pre-dialysis setting utilising liver transplantation alone is rational, feasible and effective. We support consideration of this approach to halt disease progression and prevent haemodialysis.</i></span>
</blockquote>
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So although there is not much progress toward a drug treatment for fibrinogen amyloidosis due to the small number of patients, it is the only amyloidosis type that can be said to have a cure.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Now for the exciting news I mentioned at the beginning of this blog post. Do you remember that abstract you read about just a few seconds ago, the one presented in October during Kidney Week? It already needs to be updated because another patient received a liver transplant in early December. The only detail I will mention for now is that this patient had not started dialysis, so the prospects for a successful outcome are very good.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">That makes three isolated liver transplants for fibrinogen amyloidosis patients now, with those transplants occurring in 2010, 2017, and 2018. Going forward, my hope is that as more patients are diagnosed early enough in the progression of the disease, more of them will consider a liver transplant before going on dialysis. If the doctors at the NAC in London ever start proposing liver transplants for AFib patients we will likely see many more, given the large number of patients with fibrinogen amyloidosis in the UK.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">See you next year!</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">As of September 30, 2018:</span><br />
<br style="font-family: arial, helvetica, sans-serif;" />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Total posts: 184 (1 in September)</span><br />
<br style="font-family: arial, helvetica, sans-serif;" />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Total pageviews: 99,900 (~2100 in September)</span><br />
<br style="font-family: arial, helvetica, sans-serif;" />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Email subscribers: 16 (unchanged)</span><br />
<br style="font-family: arial, helvetica, sans-serif;" />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Total number of countries that have viewed the blog: 148</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">No new countries viewed the blog in September.</span><br />
<span style="font-family: arial, helvetica, sans-serif;">=====</span><span style="font-family: "arial" , "helvetica" , sans-serif;"></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">As of October 31, 2018:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total posts: 184 (0 in October)</span><br />
<br style="font-family: arial, helvetica, sans-serif;" />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Total pageviews: 103,200 (~3000 in October)</span><br />
<br style="font-family: arial, helvetica, sans-serif;" />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Email subscribers: 15 (down by 1)</span><br />
<br style="font-family: arial, helvetica, sans-serif;" />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Total number of countries that have viewed the blog: 149</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">One new country viewed the blog in October:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Barbados" target="_blank">Barbados</a></span><br />
=====<br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">As of November 30, 2018:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total posts: 184 (0 in November)</span><br />
<br style="font-family: arial, helvetica, sans-serif;" />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Total pageviews: 108,000 (~4700 in November)</span><br />
<br style="font-family: arial, helvetica, sans-serif;" />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Email subscribers: 15 (unchanged)</span><br />
<br style="font-family: arial, helvetica, sans-serif;" />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Total number of countries that have viewed the blog: 150</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">One new country viewed the blog in November:</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Benin" target="_blank">Benin</a></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"></span>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-24766739386731547682018-09-30T12:30:00.000-04:002018-12-26T14:06:34.991-05:00I'm baaaack . . .<span style="font-family: "arial" , "helvetica" , sans-serif;">Hello, loyal fibrinogen amyloidosis blog followers. Long time, no see. I'm still here, alive and kicking, and I don't have any good excuses for the extended absence. Yes, I've been busy with life, the universe, and everything, but that's not much of an excuse. I don't think I will get back to a one post per month pace any time soon but maybe I can aim for one post per quarter.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In blog news, the total pageviews for the blog is rapidly approaching a major milestone: 100,000. It should reach that in the next day or two if it has not already. (It was within 100 of reaching it as of the morning of September 30.) At the end of this post I have the monthly blog stats for the past six months, in a consolidated format to make it a little easier to read in case anyone cares.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">There is not much happening with me health-wise, which is good. I had some lab work done this past week but I do not have the results yet. If there is anything interesting in those results I will do a post for that.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In other patient news there is a lot happening in terms of transplants, so much in fact that I may not remember them all. I know of one person who had a combined liver and kidney transplant late last year and another who had the same thing in July. Both are doing well as far as I know. There is another person currently on the waiting list for a liver transplant, and this will likely be the third case ever of a liver-only transplant for fibrinogen amyloidosis.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">I also became aware of another person diagnosed with fibrinogen amyloidosis earlier this year, and this particular case is interesting for two reasons. The first reason is the age of this patient when diagnosed: 37. The youngest age of onset of any of the other patients I am aware of is approximately 46, and I think the journal articles mention some cases of patients developing symptoms in their mid-40s. But 37 is definitely the youngest I can recall (for the Glu526Val mutation). As if that was not special enough, the other interesting thing about this case is that there is a long history of kidney disease in the family and they have Portuguese ancestry. You may recall there is a concentration of fibrinogen amyloidosis patients in the Braga district of Portugal. (My most recent blog post about that was in <a href="http://www.fibrinogenamyloidosis.com/2014/04/article-review-2011-long-term-follow-up.html" target="_blank">April of 2014</a>.) As of the date of this blog post no other family members of this patient have been tested for the mutation, but I do not think anyone will be surprised if genetic testing does show it was inherited from a Portuguese ancestor.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Getting back to some specifics regarding this case, she was found to have elevated creatinine in September of 2017, was referred to a nephrologist, and had a kidney biopsy in November of 2017. That biopsy was positive for amyloidosis but the type could not be determined. She started hemodialysis in February of 2018, and in May the original kidney biopsy was typed by Mayo Clinic as fibrinogen amyloidosis, Glu526Val mutation (or p.Glu545Val using the new nomenclature). She is about to begin evaluation for liver and kidney transplant.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Lastly, I am sure we would all prefer to have treatment options other than organ transplants. Unfortunately the number of fibrinogen amyloidosis patients is so small that our best hope is that a treatment developed for other types of amyloidosis will be effective for us, since pharmaceutical companies tend to focus on diseases with larger patient populations. However, there may be some progress in that area. Some of you may be aware of a web site called My Amyloidosis Pathfinder (<a href="https://www.myamyloidosispathfinder.org/" target="_blank">https://www.myamyloidosispathfinder.org/</a>), also known as MAP, that is for patients with any type of amyloidosis. Once a patient registers on that site, they are notified of treatment centers and clinical trials best suited for their situation.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The Amyloidosis Research Consortium monthly newsletter for July had this to say about MAP:</span><span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><br />
<blockquote class="tr_bq">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><u>Do you have a rare type of amyloidosis? MAP needs you.</u></span></blockquote>
<blockquote class="tr_bq">
<span style="font-family: "arial" , "helvetica" , sans-serif;">Just by knowing about you, we can accelerate research in your type of amyloidosis. A number of companies have expressed an interest in developing products for some of the rarer types of amyloidosis, including AA amyloidosis, beta-2 microglobulin (AB2M) amyloidosis, ALect2 amyloidosis and localized amyloidosis, among others.</span></blockquote>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br />The more patients there are with a disease, the more likely a company is to develop a product for it. So if you have not already registered at <a href="https://www.myamyloidosispathfinder.org/" target="_blank">MAP</a> and set up a profile, I hope you will consider it even if you are just a carrier of the mutation without any symptoms. We are like the Whos from "Horton Hears a Who!," and each and every one of us needs to shout, "We are here! We are here! We are here!"</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">That's it for this post. See you next . . . month? quarter? year? </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update for March through August, 2018=====</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br />As of August 31, 2018:<br /><br />Total posts: 183 (1 in March)<br /><br />Total pageviews: 97,800 (Monthly views: 1200, 1100, 6100 (includes 4600 in one day from Israel), 1000, 1500, 1500)<br /><br />Email subscribers: 16 (gained one in April, one in June)<br /><br />Total number of countries that have viewed the blog: 148<br /><br />Three new countries have viewed the blog since February:</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Aruba" target="_blank">Aruba</a></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Guyana" target="_blank">Guyana</a></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Micronesia" target="_blank">Micronesia</a></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">FYI, there is not a country named Macronesia but there is a Macaronesia.</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;">=====</span></div>
<span style="font-family: "arial" , "helvetica" , sans-serif;"></span>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-49305310766036255062018-03-31T22:00:00.000-04:002018-11-17T07:03:58.624-05:00Article Review (2012) - Amyloid diseases of the heart: Current and future therapies<span style="font-family: "arial" , "helvetica" , sans-serif;">It looks like I did not begin 2018 with one post per month, but maybe I can still finish the year with a total of 12 to get the average up to one per month. Since my last article review was published in August of 2016, I should probably start doing those again. I have not yet reviewed all the ones listed on the resources page and I have also found a few more that are not listed there. So this blog post will be my first article review in 18 months.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Before beginning the article review I thought I would mention that the XVIth (16th) International Symposium on Amyloidosis was recently held in Japan, and there were a couple of posters shown that were related to fibrinogen amyloidosis. One of the posters discussed the results of a small cohort of AFib patients (6) in Portugal who received kidney transplants. Although I have only seen a low-resolution picture of that poster, I suspect the results were mixed and showed rapid recurrence of amyloid in some of the transplanted kidneys, as we have seen in many of the articles I have previously reviewed.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The other poster I am aware of was titled "Fibrinogen A alpha-chain (AFib) renal amyloidosis: Is liver transplant alone sufficient? A case report." I have not yet seen a high-quality photo of that poster either, but from what I could tell of the picture posted in one of the Facebook groups, the case report was regarding the person with AFib who received a liver-only transplant at Mayo Clinic in March of 2017. The poster gave some data on this patient as recently as four months after the transplant, and it definitely showed improvement in kidney function. If I get a more readable version of that poster I will present some of that data in a future blog post.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The last bullet point in the Conclusions section of this poster was "Further studies are needed to assess long-term outcomes as well as the appropriate timing of the procedure during the course of the disease." Unfortunately there are only two patients available to study as far as we know, with one being the patient discussed in this case report and the other one being the patient who received a liver-only transplant in July of 2010. Hopefully earlier diagnosis and genetic testing of family members will lead to more AFib patients pursuing liver-only transplants in the near future.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Now to the article review . . .</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Title:</b> Amyloid diseases of the heart: Current and future therapies (1)</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Authors:</b> Dubrey, S. W. and Comenzo, R. L. (Hillingdon Hospital, Middlesex, UK; Tufts Medical Center, Boston, MA, USA)</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Journal:</b> QJM: An International Journal of Medicine (July 2012)</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Abstract:</b></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><i><br /></i></span><br />
<blockquote class="tr_bq">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><i>Amyloid diseases in man are caused by as many as 23 different pre-cursor proteins already described. Cardiologists predominantly encounter three main types of amyloidosis that affect the heart: light chain (AL) amyloidosis, senile systemic amyloidosis (SSA) and hereditary amyloidosis, most commonly caused by a mutant form of transthyretin. In the third world, secondary amyloid (AA) is more prevalent, due to chronic infections and inadequately treated inflammatory conditions. Much less common, are the non-transthyretin variants, including mutations of fibrinogen, the apolipoproteins apoA1 and apoA2 and gelsolin. These rarer types do not usually cause significant cardiac compromise. Occurring worldwide, later in life and of less clinical significance, isolated atrial amyloid (IAA) also involves the heart. Heart involvement by amyloid often has devastating consequences. Clinical outcome depends on amyloid type, the extent of systemic involvement and the treatment options available. An exact determination of amyloid type is critical to appropriate therapy. In this review we describe the different approaches required to treat this spectrum of amyloid cardiomyopathies.</i></span></blockquote>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">Here is a link to the article: </span><a href="http://qjmed.oxfordjournals.org/content/105/7/617.long" target="_blank">http://qjmed.oxfordjournals.org/content/105/7/617.long</a><br /><span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></span><span style="font-family: "arial" , "helvetica" , sans-serif;">After an introduction to the effects of amyloid on the heart and the methods of treatment, the article then has specific sections for each of the types of amyloidosis mentioned in the abstract. I will not cover any of those sections other than fibrinogen in this review.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The Fibrinogen Amyloidosis section of this article begins by stating nine fibrinogen mutations causing amyloidosis have been identified to date. (As of 2018, the number of mutations is 15 according to the data at <a href="http://amyloidosismutations.com/" target="_blank">amyloidosismutations.com</a>.) It then presents some general information about fibrinogen amyloidosis we are very familiar with, such as the usual presentation being nephropathy leading to kidney failure if left untreated. It then mentions kidney transplantation as a treatment option, which usually leads to rapid recurrence of amyloid in the transplanted kidney.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In the section on combined liver and kidney transplantation for fibrinogen amyloidosis, the article mentions a study of nine patients in which six survived with good results. There is also a mention that a liver-only transplant may be an option to prevent progression of the disease to other organs. It does state that no patient has undergone a combined liver and heart transplant for AFib.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">There is not really any new information in this article that has not been covered in previous articles. We know fibrinogen amyloidosis initially affects kidney function, but in the later stages of the disease it can affect other organs such as the spleen, liver and heart. But I am aware of only one documented case of significant cardiac involvement in a patient with fibrinogen amyloidosis. That case was described in a 2008 article in the New England Journal of Medicine, which I reviewed in the blog on </span><a href="http://www.fibrinogenamyloidosis.com/2014/01/article-reviews-2008-cardiac.html" style="font-family: arial, helvetica, sans-serif;" target="_blank">January 6, 2014</a><span style="font-family: "arial" , "helvetica" , sans-serif;">. Oddly enough, that 2008 NEJM article was not listed among the references for this 2012 article for some reason.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">As of January 31, 2018:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total posts: 182 (1 in January)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total pageviews: 82,800 (~1600 in January)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Email subscribers: 14 (unchanged)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Total number of countries that have viewed the blog: 145</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">No new countries viewed the blog in January.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====<br /><br />As of February 28, 2018:<br /><br />Total posts: 182 (0 in February)<br /><br />Total pageviews: 84,700 (~1900 in February)<br /><br />Email subscribers: 14 (unchanged)<br /><br />Total number of countries that have viewed the blog: 145<br /><br />No new countries viewed the blog in February.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">Citation:</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">(1) Dubrey SW, Comenzo RL. Amyloid diseases of the heart: current and future therapies. QJM. 2012;105(7):617-631.</span><br />
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Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-16576430648969938792018-01-30T21:00:00.000-05:002018-03-21T10:34:08.690-04:00Happy New Year!!!!!!<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;"><span style="color: black; font-size: small;">Welcome to 2018 everyone. In keeping with my tradition, there are six exclamation points in the title since this is my sixth Happy New Year post in the history of this blog.</span></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Here is what happened with the blog in 2017:</span></div>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">8 new blog posts were written. (Down from 11 in 2016)</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">No new articles were reviewed. :-(</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">13 additional countries visited the blog, bringing the total to 145.</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">The blog received 13 spam comments in 2017, two of which complimented me on my excellent use of colors in the design of the blog.</span></li>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The big news in the world of fibrinogen amyloidosis this year, which I mentioned in the December 31, 2017 post, is that another liver-only transplant for fibrinogen amyloidosis was performed in March of 2017.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In personal news, my problem with anemia that was being investigated in 2016 is definitely behind me, and I remain asymptomatic as of August of 2017. The really big non-medical news for me in 2017 was a move from Texas to North Carolina in June. That kept me rather busy and was a handy excuse to keep from spending much time on the blog, so now that we are settled in I can hopefully get back to publishing an article monthly or almost monthly.</span></div>
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<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;"><br /></span>
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;">=====Monthly Blog Status Update=====</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">As of December 31, 2017:</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total posts: 181 (1 in December)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total pageviews: 80,900 (~5800 in December, thanks to another spike of ~4500 in one day from Israel)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Email subscribers: 15 (unchanged)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total number of countries that have viewed the blog: 145</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">No new countries viewed the blog in December.</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">=====</span>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-29231418475097476712017-12-31T13:00:00.000-05:002017-12-31T13:00:34.861-05:00Charlotte Support Group Meeting: November 18, 2017<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;">End-of-year greetings, loyal blog readers. In this post I have some exciting news in the world of fibrinogen amyloidosis, followed by a report of a local support group meeting, some interesting data I recently gathered, and finally the oh-so-exciting monthly blog stats.</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;"><br /></span>
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;">First, the exciting news. In November, shortly after I returned from the hereditary amyloidosis support group meeting in Chicago, I learned that another liver-only transplant for fibrinogen amyloidosis occurred in March of 2017 at Mayo Clinic. As far as I know, this is only the second liver-only transplant ever for fibrinogen amyloidosis, with the first one occurring in 2010. The most recent transplant recipient is a female in her early 50s who initially presented with proteinuria in August of 2015. She is currently doing very well post-transplant. The outcome of this case will be very important to patients in a similar position in the future, since this transplant occurred relatively early in the progression of the disease. I may have some more to say about this particular case in the near future as part of a larger discussion about organ transplants for fibrinogen amyloidosis.</span><br />
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<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;">On Saturday, November 18 I attended the amyloidosis support group meeting in Charlotte, North Carolina. But David, don't you go to the Dallas support group meetings? Well, not any more since we moved to North Carolina this summer. The closest support group meeting to me now is in Charlotte, and currently those are held once per year. At this meeting there were two local doctors from Levine Cancer Institute, and Dr. Eli Muchtar from Mayo Clinic in Rochester. I think there were around 45 people in attendance at this meeting, and almost all patients had AL or ATTR. I think there were one or two patients with localized amyloidosis (including the facilitator), and I was the only one with a rare hereditary type.</span><br />
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<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;">Now, the interesting data I recently gathered has to do with the number of other people I have been in contact with who also have fibrinogen amyloidosis. I first became aware of fibrinogen amyloidosis when my mother was diagnosed in 2010, and I started this blog in 2012, so I've been in contact with many patients with AFib through the blog and various other web sites over the past seven years. But I did not realize how many until I started going through some old emails and consolidating that information. I will use the term "kindred" here instead of "family." (People in the same kindred are biologically related, whereas people in the same family can be related biologically or by other means such as marriage or adoption.) Not counting my own kindred, I have been in contact with people from 12 other kindreds in which at least one person has been diagnosed with fibrinogen amyloidosis. I believe seven of these kindreds are based primarily in the US and the other five are based primarily in the UK.</span><br />
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<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;">There is another large kindred in the UK (Scotland) I have not been in contact with but am somewhat familiar with because their story has been told in at least three separate articles on the internet (see below). You won't see the word "fibrinogen" in any of those articles, but some excellent detective work by somebody (not me) did uncover the fact that fibrinogen amyloidosis is the type this family has.</span><br />
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<span style="background-color: white; color: #222222; font-family: arial, helvetica, sans-serif; font-size: 13.2px;"><a href="http://www.eveningtimes.co.uk/news/13271564.Help_beat_the_disease_that_killed_my_mum__aunt__uncle_and_grandfather/" target="_blank">http://www.eveningtimes.co.uk/news/13271564.Help_beat_the_disease_that_killed_my_mum__aunt__uncle_and_grandfather/</a></span><br />
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<span style="background-color: white; color: #222222; font-family: arial, helvetica, sans-serif; font-size: 13.2px;"><a href="http://www.dailymail.co.uk/news/article-3425394/Four-members-family-killed-genetic-condition-surviving-relatives-chance-suffering-too.html" target="_blank">http://www.dailymail.co.uk/news/article-3425394/Four-members-family-killed-genetic-condition-surviving-relatives-chance-suffering-too.html</a></span><br />
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<span style="background-color: white; color: #222222; font-family: arial, helvetica, sans-serif; font-size: 13.2px;"><a href="https://www.sundaypost.com/news/scottish-news/one-by-one-our-family-is-dying-from-a-deadly-genetic-defect-as-survivors-agonise-over-test-choice/" target="_blank">https://www.sundaypost.com/news/scottish-news/one-by-one-our-family-is-dying-from-a-deadly-genetic-defect-as-survivors-agonise-over-test-choice/</a></span><br />
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<span style="background-color: white; color: #222222; font-family: arial, helvetica, sans-serif; font-size: 13.2px;">On a separate note, I received an email this week announcing that the 2019 Hereditary Amyloidosis Support Group Meeting will be October 25, 26 and 27 in Chicago. So mark your calendars. (If you have a 2019 calendar.)</span><br />
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<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;">=====Monthly Blog Status Update=====</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">As of November 30, 2017:</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total posts: 180 (3 in November)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total pageviews: 75,100 (~1300 in November)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Email subscribers: 15 (unchanged)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total number of countries that have viewed the blog: 145</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">One new country viewed the blog in November:</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Belize</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">=====</span>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-67559547238689371642017-11-12T21:29:00.000-05:002017-11-12T21:29:37.727-05:002017 Hereditary Amyloidosis meeting - Sunday<span style="font-family: "arial" , "helvetica" , sans-serif;">Today's post will cover the last day of the 2017 Hereditary Amyloidosis support group meeting in Chicago. The Sunday agenda is always just half a day, with the doctors answering questions submitted by attendees. The session is moderated by Dr. Gertz, who goes through the stack of questions and decides which questions to ask and which doctor or doctors to give the questions to. I have submitted questions in the past for the Sunday session, and I submitted a two-part question this time as well.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">If you recall from my blog post about the Saturday presentations, Dr. Benson did discuss the difference in numbers (when referring to a specific mutation) when the full length of the protein (including the signal peptide) is considered vs. when the length of the mature protein is considered (not including the signal peptide). He discussed the length of the signal peptide for transthyretin (TTR) which is 20, meaning you just add or subtract 20 to get from one number to the other. But he did not mention the signal peptide length of the other proteins that can cause hereditary amyloidosis, such as fibrinogen, lysozyme, apolipoprotein, or gelsolin. When the report from the nomenclature committee came out last year I looked up somewhere that the length of the signal peptide for fibrinogen was 19, not 20 like TTR. I don't recall what the length is for the other rare ones, but if I remember correctly they are not 20 either. Since I would not want anyone leaving the meeting thinking their signal peptide length was 20 when it is really something else (knowing very well that I was probably the only person there who cared), I submitted two related questions:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Question 1: What is the signal peptide length of the amyloidogenic proteins other than TTR?</span></i><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">I was hoping the question would go to Dr. Benson and he would say the signal peptide length is 20 for TTR but it is 19 for fibrinogen, xx for apolipoprotein, yy for lysozyme, etc., and then talk about how confusing it will be to get everyone on the same page. That leads to my second question:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><i>Question 2: Will Dr. Benson promise not to retire before everyone is comfortable with the new recommendations of the nomenclature committee?</i></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">For those of you who don't know, Dr. Benson is probably past normal retirement age. He received his bachelor's degree in 1961 and his MD in 1965, so he has been practicing medicine for over 50 years. Given his expertise and experience, especially in discovering many of the mutations that cause hereditary amyloidosis (including some of the fibrinogen mutations), his retirement will likely have a huge impact on both patients and doctors in the amyloidosis community. So my second question was obviously intended to bring a little levity to the proceedings. Dr. Benson has a very quick wit and a dry sense of humor, so I felt certain he would have an entertaining answer to the question.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">With so many attendees at this year's meeting, Muriel announced before the session started that if they did not get to all of the questions they would try to get answers later and make those answers available in a document they would let everyone know about. Typically she will publish all of the answers from the Q and A session, but as of this writing she has not. If and when she does I will update this post and also mention it in the next new post.</span><br />
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<span style="font-family: arial, helvetica, sans-serif;">So the Question and Answer session starts Sunday morning, with Dr. Gertz reading the questions out loud and then having the appropriate doctor answer them. As usually happens during the Sunday session, some doctors need to leave before the session is over at noon in order to catch their flights back home. As the morning went on, a few doctors got up from their seats in the front of the room and started walking down the center aisle toward the exit at the back. Dr. Gertz would notice the doctor leaving and say something like "Thanks to Dr. So-and-so," prompting the audience to give that doctor a round of applause. Well, much to my surprise, Dr. Benson got up and left at some point before 10 AM. That, of course, means my first question will either not be asked at all or will be answered by one of the other doctors. And if Dr. Benson is not there, there is no point in asking my second question. Well, that was a missed opportunity.</span><br />
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<span style="font-family: arial, helvetica, sans-serif;">Although most of the questions asked during the Sunday session do not relate to fibrinogen amyloidosis because many of them are questions about symptoms typically not associated with AFib or questions about the drugs for ATTR currently in clinical trials, I do enjoy the Sunday session anyway since I find most of the topics discussed very interesting and informative. It is also interesting to hear different doctors respond to the same question as they all have their unique perspective.</span><br />
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<span style="font-family: arial, helvetica, sans-serif;">Then much to my surprise, about 20 minutes before the scheduled noon end time, Dr. Gertz must have gotten to the sheet of paper with both of my questions. I heard him read my second question first, somewhat quickly and quietly to himself, and he got a little chuckle out of it. Then he said something about the next question (referring to my Question 1) being for Dr. Benson but he has already gone. A couple of people then spoke up and said Dr. Benson was actually still there, and lo and behold he did make his way from the back of the room to a microphone stand in about the middle of the aisle.</span><br />
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<span style="font-family: arial, helvetica, sans-serif;">Dr. Gertz asked Dr. Benson my first question about the signal peptide lengths, and he gave a long answer that went into some of the science behind what actually happens with the signal peptide. But he did eventually get around to the point that with TTR it's easy to do the math because you just add 20, whereas with something like fibrinogen "I have to get out my calculator because I have to add 19." I don't think he mentioned the lengths of any of the others, but I was glad he at least confirmed what I thought I knew about fibrinogen. Unfortunately Dr. Gertz did not ask Dr. Benson my second question at this point, which is too bad. He was probably trying to get a few more questions answered since he was running out of time.</span><br />
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<span style="font-family: arial, helvetica, sans-serif;">Since the subject of nomenclature and this numbering scheme can lead to some confusion due to the different ways a genetic mutation can be written (I have seen the most common AFib mutation written at least three different ways in published medical journal articles), I will go over that in a separate post.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Around noon the meeting ended and we all had lunch, which included cookies for dessert because Dr. Benson had asked Muriel Finkel specifically for that. Cathy and I then said our goodbyes to Cathy T. and Lon before heading to the airport to catch our flight back home. We had a few hours before our flight, so I took Cathy on the full tour of O'Hare Airport since she had never been there before. If you ever have time to walk around inside O'Hare Airport in Chicago, do it. Much of it is just like any other airport, but there are a few interesting things to see.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">That wraps up the 2017 Hereditary Amyloidosis meeting in Chicago. There was an evaluation sheet we completed after the meeting, and one of the questions asked where we would like to see the next meeting held in 2019. The choices were Chicago, Phoenix, Baltimore, Jacksonville, and Salt Lake City. I will be surprised if Muriel has it some place other than Chicago, but I suppose she is open to the idea since she asked the question. I plan on being there, wherever it is.</span>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-83742336023417460342017-11-11T23:00:00.000-05:002018-12-24T21:30:36.021-05:002017 Hereditary Amyloidosis meeting - Saturday<span style="font-family: "arial" , "helvetica" , sans-serif;">Hello again, loyal blog readers. Are you shocked to see two posts in two days? I decided to publish my blog posts about the Chicago meeting over the course of three days, just like the meeting. So it is sort of like live-blogging, but two weeks after the event.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">After breakfast Saturday morning (October 28) I headed to the Grand Ballroom for the meeting. I arrived about 40 minutes before the scheduled start time of 8:00 AM, and here is what the meeting room looked like from the back of the room:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">As you can see, it was almost wall-to-wall chairs. I don't think the rows went that far back for the 2015 meeting. Not counting the partial rows of chairs where that screen was set up on the left side, I counted 18 rows of 22 chairs this time, which is 396. Add to that at least six rows of 11 chairs where the screen was, and now we're up to at least 462 chairs. That's a lot of chairs, and as you can see from a picture I took later in the day, they were needed.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">I was also able to get some pictures of the dais at the front of the room before any of the doctors arrived.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">(Note: As of the writing of this blog post the presentations from the meeting have not been posted online. If and when they are made available, I will update this post and also mention it in the next new blog post.)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">After the introductory remarks by Muriel Finkel and Dr. Gertz, Dr. Benson gave the first presentation of the meeting. His topic was nomenclature, which is an appropriate topic for him to discuss because he is on the amyloidosis nomenclature committee. In my <a href="http://www.fibrinogenamyloidosis.com/2016/12/familial-or-hereditary.html" target="_blank">December 31, 2016</a> blog post I mentioned some changes recommended by the nomenclature committee in 2016. One of those was to use the term hereditary amyloidosis to refer to amyloidosis due to a mutation in the fibril protein itself, which is the case in fibrinogen amyloidosis. Dr. Benson did not discuss that in his presentation, but he did discuss the recommended change (which I don't see in the article I linked to in the December 31, 2016 blog post) in the numbering scheme for hereditary amyloidosis mutations.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The number typically used in the designation of a mutation is referring to the position of the change in the mature protein. But Dr. Benson explained that when a protein is initially created, there is a short section of it called the signal peptide that gets removed as the protein leaves the cell to go into the body and do its job. Dr. Benson only discussed the TTR protein, in which the signal peptide has a length of 20 amino acids. So the number used when referring to a position in the complete TTR protein (with the signal peptide) would be 20 more than the number used when referring to the mature protein (without the signal peptide). He didn't discuss the other amyloid proteins such as fibrinogen, lysozyme, etc., so keep that in mind for the next blog post.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The next presentation covered TTR amyloidosis (both mutant and wild type), and then the one after that was Dr. Berk's presentation on the non-ATTR varieties. Here are the notes I took during the fibrinogen portion of his presentation:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"> - The annual decline in GFR for AFib patients is approximately 11.2. (In the past I had heard that 15 was the estimated annual decline.)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"> - Biopsy slides of kidneys impacted by AFib show clear glomerular involvement. (We have seen that in medical journal articles I reviewed previously in the blog.)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"> - One of the slides presented the data on transplant outcomes for AFib from one of the articles by the NAC in London. This was probably the 2009 article I reviewed in the <a href="http://www.fibrinogenamyloidosis.com/2014/01/article-review-2009-diagnosis.html" target="_blank">January 12, 2014</a> blog post, so no real surprises there. The main takeaway from that data is a kidney transplant by itself will likely result in the transplanted kidney developing amyloidosis almost certainly within ten years, sometimes within a year or two. A combined liver-kidney transplant yields better results, but there are increased risks associated with that option.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"> - Dr. Berk also mentioned that there was one patient </span><span style="font-family: "arial" , "helvetica" , sans-serif;">(not part of the NAC study)</span><span style="font-family: "arial" , "helvetica" , sans-serif;"> who had received a liver-only transplant for AFib before going on dialysis, and was still alive seven years post-transplant. (He did not mention that the patient was sitting next to me at the time.)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">There was a question and answer session after Dr. Berk's presentation, and Cathy T. asked how the US experience with organ transplants compares with the experience in the UK. The answer, unfortunately, is that nobody knows because the experience in the US is not consolidated anywhere. In the UK, all amyloidosis patients are referred to the NAC so it is much easier to collect information on all of the AFib patients there.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The next presenter was a genetic counselor from Mayo Clinic. I always enjoy these presentations because I get a little more out of each one and they always help me understand how others may feel about genetic testing. There were three items I made a note of during this presentation. First was the importance of having open communication among family members. The second was when the counselor talked about putting together a family letter to communicate to the potentially affected family members. If you go back to the entries in this blog from right after Mom was diagnosed with AFib, you'll find the family letter I put together to send to her cousins. The third item I made a note of was a recommendation from the counselor to identify the communicator in the family, which would be the person in the family with the most information about the disease and the ability to communicate with everyone who needs to be kept informed. I suppose I jumped right into that position when Mom was diagnosed.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Next was Dr. Picken, a pathologist who spoke about methods of diagnosing amyloidosis, and then Dr. Grogan, a cardiologist from Mayo Clinic. A topic that generated some discussion in her presentation was a test called the PYP scan that is being used to diagnose amyloid involvement in the heart.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Next was Dr. Waddington-Cruz from Brazil with a presentation on neuropathy, followed by Dr. Clarke on gastrointestinal issues and Dr. Dispenzieri on solid organ transplants. Very little if any from those presentations was applicable to AFib.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Then it was time for lunch. That was a very full morning, wasn't it?</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">After lunch there were presentations by four different pharmaceutical companies on the status of some of the clinical trials underway for drugs intended to help ATTR patients. The good news is that there is some real progress being made in that area. The bad news is that none of these drugs currently in clinical trials will benefit AFib patients since they are intended to prevent or dissolve the buildup of TTR amyloid fibrils. The next presenter was Dr. Berk again who discussed a few other treatments that were not in clinical trials. Regarding doxycycline, which Boston University did study in a clinical trial, he said they did not see much benefit and there were some adverse effects.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">After those presentations we divided into five breakout sessions, where different rooms are set up to discuss different topics and attendees can go to the room or rooms of their choosing. Cathy, Lon and I went to the session titled "Genetic Issues and Non-ATTR variants." There was some good discussion of the issues surrounding genetic testing, especially with regard to children and young adults. We did not ask any questions about fibrinogen amyloidosis, but some of the other people with non-ATTR variants did ask some questions about those.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">That concludes the meeting agenda for Saturday. We have already answered the first question posed at the end of the previous blog post. Yes, all of this year's attendees did fit in the Grand Ballroom. But what about the second question? Did my wife brave the cold and go back to downtown Chicago on Saturday? No she did not. I can't say that I blame her, either. It was cold.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Next up is the Sunday Question and Answer session.</span>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-67402039443914122032017-11-10T20:00:00.000-05:002018-12-24T21:17:10.752-05:002017 Hereditary Amyloidosis meeting - Friday<div>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Greeting, loyal Fibrinogen Amyloidosis blog followers. The number of email subscribers increased by one last month (first time in quite awhile), so I'd like to extend a special welcome to our newest subscriber. (I can only see the number of subscribers, not the email addresses.) As a reminder to email subscribers, the formatting of emails is sometimes not as good as the formatting of the blog post. So if the email looks awful, check the blog.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">As I mentioned in the previous post, at the end of October I traveled to Chicago to attend the hereditary amyloidosis support group meeting that occurs every two years. (Side note: The word "biannual" can mean occurring twice a year (semiannual), or occurring once every two years (biennial). Isn't English a great language?) This was my fourth time to attend this meeting, having attended in 2011 and 2013 with Mom, and by myself in 2015. This year my wife Cathy was able to travel with me, so we decided to travel to Chicago Thursday evening and visit downtown Chicago together on Friday, and then Cathy would do her own thing on Saturday and Sunday while I attended the meeting. I'll blog about the meeting over three posts, with this first post covering the Friday before the meeting including the Meet-and-Greet Friday night.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">When we flew in Thursday night the temperature was in the 50s, but we knew from the weather forecast that we wouldn't see 50 degrees again that weekend in Chicago. The weather forecast was indeed accurate. Friday morning we took the train from O'Hare airport to downtown Chicago and walked a few blocks to the Willis Tower (formerly Sears Tower) to go to the observation deck (Skydeck) on the 103rd floor. Here is the obligatory picture of our feet while we were standing on the Ledge, which is a series of four glass boxes that extend just over four feet outside the building, 103 floors up.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">After visiting the Skydeck we took a Hop On-Hop Off bus to Millennium Park where we walked around looking at the various art installations. Here is the obligatory picture of our reflection in The Bean (Cloud Gate). I'm wearing a gray hat.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br />It was definitely cold while we were walking around Millennium Park, but we survived. We then made our way a few blocks north to have lunch before the 2 PM boat tour we had reservations for. We managed to stay on the upper deck for most of the boat tour so we could see the buildings along the Chicago River. (It was an architectural tour, after all.) But once the boat went out on Lake Michigan and started going a little faster we decided to go down below to an enclosed area with windows and have some hot chocolate. It was only then that I realized how cold my hands really were. I haven't been that cold in a very long time.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">After the boat tour we walked around a bit, got on the Hop on-Hop off bus again to go through a little more of downtown Chicago, and then we got off close to a subway station to catch the train back to the airport.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">After not having the traditional Friday evening Meet-and-Greet in 2015, it was back for the 2017 meeting. We found Cathy T. and her husband Lon, and it was good to catch up with them. Cathy's doing well 7 years after her liver transplant for fibrinogen amyloidosis. Just before we left we spoke with Dr. Benson for awhile. He was not aware of anything new with regard to fibrinogen amyloidosis, unfortunately. One of the topics discussed was liver-only transplants for fibrinogen amyloidosis patients, which he is still in favor of despite the reluctance of the doctors at the NAC in London to embrace it. He was not aware of any other liver-only transplants for AFib besides Cathy's.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">That concludes the Friday before the actual start of the meeting. Tomorrow we'll answer two important questions:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">1. Will all of this year's participants fit in the Grand Ballroom at the O'Hare Hilton? It seemed almost full in 2015, and this year's attendance is probably 30 to 40% more.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">2. Will Cathy (my wife) brave the cold on Saturday and go back to downtown Chicago as planned?</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Stay tuned . . .</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====<br /><br />As of September 30, 2017:<br /><br />Total posts: 177 (1 in September)<br /><br />Total pageviews: 72,700 (~1100 in September)<br /><br />Email subscribers: 14 (unchanged)<br /><br />Total number of countries that have viewed the blog: 142<br /><br />No new countries viewed the blog in September:</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====<br /><br />As of October 31, 2017:<br /><br />Total posts: 177 (0 in October)<br /><br />Total pageviews: 73,800 (~1000 in October)<br /><br />Email subscribers: 15 (increased by 1)<br /><br />Total number of countries that have viewed the blog: 144<br /><br />Two new countries viewed the blog in October:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====</span>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-62018667936259176182017-09-30T12:00:00.000-04:002017-09-30T12:00:20.556-04:00Still here<div>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Hello again, loyal blog readers. We've had another really long time period between posts due to lots of other stuff going on, but hopefully I will settle into my new normal and resume posting on a more regular basis.</span><br />
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<span style="font-family: arial, helvetica, sans-serif;">The first thing I need to mention is the upcoming hereditary amyloidosis support group meeting in Chicago that's held every two years. It is the last weekend in October, which is less than one month away now. Here is a link with more info on the meeting: http://amyloidosissupport.org/support_groups/familial.html. Note that attending the meeting is free, you just have to register for it. They are once again having the meet and greet Friday night at the hotel, which is a great time to meet other people dealing with similar issues. So if you are planning on being there and would like to get together, send me an email to toe at juno dot com.</span><br />
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<span style="font-family: arial, helvetica, sans-serif;">Health-wise I am still doing fine. Due to our recent move from Texas to North Carolina I had to find a new primary physician. I won't have a physical exam until March, but my new doctor did go ahead and order lab work in August to make sure there was not anything that needed immediate attention. Everything looked good, with none of the biomarkers related to kidney function out of range. My creatinine was 1.03 and GFR was greater than 59. No anemia issues, either, as my hemoglobin was 16.1.</span><br />
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<span style="font-family: arial, helvetica, sans-serif;">Due to how long it has been between postings, here are the monthly blog stats for the previous four months. In that time period we had three new countries visit the blog (Jersey, Grenada, and Curacao), and there was another day with a huge number of hits (~4000) from Israel for some reason.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====<br /><br />As of May 31, 2017:<br /><br />Total posts: 176 (1 in May)<br /><br />Total pageviews: 64,100 (~1300 in May)<br /><br />Email subscribers: 14 (unchanged)<br /><br />Total number of countries that have viewed the blog: 140<br /><br />One new country viewed the blog in May:</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Jersey" target="_blank">Jersey</a></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====<br /><br />As of June 30, 2017:<br /><br />Total posts: 176 (0 in June)<br /><br />Total pageviews: 65,200 (~1100 in June)<br /><br />Email subscribers: 14 (unchanged)<br /><br />Total number of countries that have viewed the blog: 140<br /><br />No new countries viewed the blog in June.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====<br /><br />As of July 31, 2017:<br /><br />Total posts: 176 (0 in July)<br /><br />Total pageviews: 70,300 (~5000 in July)<br /><br />Email subscribers: 14 (unchanged)<br /><br />Total number of countries that have viewed the blog: 141<br /><br />One new country viewed the blog in July:</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Grenada" target="_blank">Grenada</a></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====<br /><br />As of August 31, 2017:<br /><br />Total posts: 176 (0 in August)<br /><br />Total pageviews: 71,300 (~1000 in August)<br /><br />Email subscribers: 14 (unchanged)<br /><br />Total number of countries that have viewed the blog: 142<br /><br />One new country viewed the blog in August:</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Cura%C3%A7ao" target="_blank">Curacao</a></span></div>
<span style="font-family: arial, helvetica, sans-serif;">=====</span><span style="font-family: "arial" , "helvetica" , sans-serif;"></span>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-65898596223263105242017-05-31T23:20:00.000-04:002017-09-10T07:17:47.638-04:00Catching up<div>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Hello, loyal blog readers. Long time, no see. I am still here, just super busy with all the stuff going on in my life at the moment, most of it being very good. Today's post will be a quick update on me, a discussion of the blog stats from the past three months, and then some sad AFib family news.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In the previous blog post from three months ago (wow) I reported that my anemia appears to be gone now since my hemoglobin, ferritin, and other numbers from blood work are in the normal range. Since then I was brave enough to schedule another blood donation in April. I donated platelets instead of red blood cells, so there should have been very little stress on my body's ability to reproduce red blood cells. I will definitely wait until this fall before I consider donating again, to be on the safe side.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">At the end of this blog post I have not one, not two, but three months of blog stats. One strange blip in the data occurred in February when the blog received 4500 pageviews from Israel in just one day. The average number of pageviews for an entire month, from all countries, is under 2000. So that one day with 4500 pageviews definitely skewed the numbers a bit, as you can see in the chart below which shows monthly page views since the first blog post in September of 2012. I suspect these 4500 views were from a bot of some sort (like most of the hits from Russia and Ukraine probably are). Either that, or a group of people in Israel teamed up to view an average of just over three blog pages per minute for 24 hours.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In AFib family news, we lost a member of our collective family in March, at the age of 78. I referred to this person in my blog post about <a href="http://www.fibrinogenamyloidosis.com/2013/11/2013-familial-support-group-meeting-day.html" target="_blank">Day 1</a> of the 2013 Familial Support Group meeting, where I met her and some of her family. As far as I know she did not have any organ transplants for her fibrinogen amyloidosis.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Speaking of the Familial Support Group meeting, the next one (which I will now refer to as the Hereditary Amyloidosis Support Group meeting) is less than five months away. I plan on being there, and it would be nice to meet some of the recently diagnosed people I have been in contact with in the past year or two. Hopefully the Fibrinogen Alliance can make a good showing this year. Here is the link with dates and registration information for the meeting: </span><span style="font-family: "arial" , "helvetica" , sans-serif;">http://amyloidosissupport.org/support_groups/familial.html.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">That's about it for this blog post. I did recently obtain several articles that are not freely available on the internet, so you can expect the article reviews to resume soon. But probably not in June.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====<br /><br />As of February 28, 2017:<br /><br />Total posts: 175 (1 in February)<br /><br />Total pageviews: 60,200 (~6200 in February)<br /><br />Email subscribers: 14 (unchanged)<br /><br />Total number of countries that have viewed the blog: 134<br /><br />One new country viewed the blog in February:</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /><a href="https://en.wikipedia.org/wiki/Maldives" target="_blank">Maldives</a></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====<br /><br />As of March 31, 2017:<br /><br />Total posts: 175 (0 in March)<br /><br />Total pageviews: 61,800 (~1600 in March)<br /><br />Email subscribers: 14 (unchanged)<br /><br />Total number of countries that have viewed the blog: 139<br /><br />Five new countries viewed the blog in March:</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /><a href="https://en.wikipedia.org/wiki/Armenia" target="_blank">Armenia</a></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Botswana" target="_blank">Botswana</a></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Montenegro" target="_blank">Montenegro</a></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====<br /><br />As of April 30, 2017:<br /><br />Total posts: 175 (0 in April)<br /><br />Total pageviews: 62,800 (~900 in April)<br /><br />Email subscribers: 14 (unchanged)<br /><br />Total number of countries that have viewed the blog: 139<br /><br />No new countries viewed the blog in April.</span><br />
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Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-35827968335150058672017-02-28T23:00:00.001-05:002021-04-05T19:56:50.707-04:00Anemia begone!<span style="font-family: "arial" , "helvetica" , sans-serif;">Since February is a short month, this will be a short post with a quick but important update on me. As you may recall, in early 2016 I was diagnosed with iron deficiency anemia, which led to a series of tests to rule out internal bleeding as the cause. After having my entire GI tract cleansed, inspected, and photographed from one end to the other and finding no abnormalities, I was referred to a hematologist who had me start taking iron supplements in September. That seemed to turn things around as you can clearly see in the chart below:</span><br />
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<img height="237" 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" 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<span style="font-family: "arial" , "helvetica" , sans-serif;">I took the iron supplements from the middle of September through the end of December of 2016, which brought my hemoglobin up from 13.3 to 15.3. More importantly, my ferritin level increased over this same time period from 5 to 28. I was curious to see what would happen after I stopped taking the iron supplements, and I received the good news at my annual physical exam on February 24 that my hemoglobin went up to 15.9, which was normal for me before I started donating blood in 2013. The really good news is that my ferritin increased to 41.7 (normal ferritin level is approximately 24 to 336 ng/mL), indicating my body is able to store iron in sufficient quantities again. All the other numbers related to the red blood cells were within the normal range except one, which was barely outside the normal range.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">I think it is safe to say the anemia scare is over and appears to have been caused by donating blood more frequently than my body could handle, although the frequency was within the guidelines of the donation center. Lesson learned there. And my kidney function is fine, so I can consider myself asymptomatic for another year. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====<br /><br />As of January 31, 2017:<br /><br />Total posts: 174 (1 in January)<br /><br />Total pageviews: 54,100 (~1300 in January)<br /><br />Email subscribers: 14 (unchanged)<br /><br />Total number of countries that have viewed the blog: 133<br /><br />One new country viewed the blog in January:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Uganda" target="_blank">Uganda</a></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====</span></div>
Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com1tag:blogger.com,1999:blog-4284577738924004196.post-23406839404531965762017-01-31T21:00:00.000-05:002017-01-31T21:00:00.846-05:00Happy New Year!!!!!<span style="font-family: "arial" , "helvetica" , sans-serif;">Welcome to 2017 everyone. In keeping with my tradition, there are five exclamation points in the title since this is my fifth Happy New Year post in the history of this blog.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">This post will be a recap of 2016, followed by some musings about where things go from here.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Here is what happened with the blog in 2016:</span></div>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">11 new blog posts were written. (Down from 17 in 2015)</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">6 articles were reviewed. (Up from 4 in 2015)</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">24 additional countries visited the blog, bringing the total to 132. (That is more new country visits than occurred in 2015 (7) or 2014 (22).)</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">The blog received only 1 spam comment in 2016, which heaped a great deal of praise upon Dr. Ogun, the great healer, whose amazing herbal remedies cured the commenter of his KINDLY PROBLEM.</span></li>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In personal news, at my annual physical exam in February of 2016 my doctor informed me that I had iron-deficiency anemia. That led to the following series of tests to check for sources of bleeding in my GI tract:</span></div>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;"><b>February:</b> Colonoscopy and endoscopy</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;"><b>May:</b> Small bowel follow through exam</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;"><b>June:</b> Capsule endoscopy #1 (camera did not work)</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;"><b>July:</b> Capsule endoscopy #2 (camera did work)</span></li>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Since no abnormalities were found during any of those tests, I saw a hematologist in September who recommended I start taking iron supplements as a first step to see how my body responded. By late December my hemoglobin and ferritin were back in the normal range, as were the other numbers related to red blood cells, so I stopped taking iron supplements at the end of the year. We will see where those numbers are at my next physical exam in February.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">That wraps up 2016. There are a few recent articles I still hope to review in 2017, and there are a few blog-related projects that I hope to make some progress on. And of course the big event in 2017 is the hereditary amyloidosis support group meeting in Chicago the last weekend of October. More information and a link to register for that meeting can be found here: </span><span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="http://amyloidosissupport.org/support_groups/familial.html" target="_blank">http://amyloidosissupport.org/support_groups/familial.html</a>. Hopefully we can have a large turnout for the Fibrinogen Alliance.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br />=====Monthly Blog Status Update=====<br /><br />As of December 31, 2016:<br /><br />Total posts: 173 (1 in December)<br /><br />Total pageviews: 52,800 (~1400 in December)<br /><br />Email subscribers: 14 (unchanged)<br /><br />Total number of countries that have viewed the blog: 132<br /><br />No new countries viewed the blog in December.</span></div>
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Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-77876716921946552132016-12-31T22:15:00.000-05:002018-09-06T07:06:20.730-04:00Familial or Hereditary?<span style="font-family: "arial" , "helvetica" , sans-serif;">Hello, loyal blog readers. This final post of the year will have an update on my health and a few other minor things going on in the world of amyloidosis.<br /><br />First, it looks like I may not have a type of familial amyloidosis after all. I may actually have a type of hereditary amyloidosis instead. "But David, isn't familial the same thing as hereditary?" Generally speaking those two terms are synonymous and often used interchangeably. However, in terms of describing amyloidosis it turns out there is a need to make a distinction between the two.<br /><br /> According to the article <a href="http://www.tandfonline.com/doi/full/10.1080/13506129.2016.1257986">Amyloid fibril proteins and amyloidosis: chemical identification and clinical classification: International Society of Amyloidosis 2016 Nomenclature Guidelines</a> (1), in July of 2016, the Nomenclature Committee of the International Society of Amyloidosis met to make recommendations regarding the nomenclature for amyloid fibril proteins and the clinical classification of the amyloidoses. These recommendations are necessary to standardize how to refer to the various types of amyloidosis. For instance, this committee recommended that the term "senile systemic amyloidosis" be replaced with "wild-type ATTR amyloidos" now that the wild-type TTR protein is known to be the cause of that disease.<br /><br /> Regarding "familial" vs. "hereditary" the committee made the following recommendation:<br /><br /><i>The terms “hereditary amyloidosis” and “familial amyloidosis” refer to different entities. The term “hereditary amyloidosis” should be used when there is a mutation in the fibril protein gene itself, e.g. ATTR, ALys or AFib. The term “familial amyloidosis” should be used when the syndrome occurs in a familial setting due to mutations in genes expressing non-amyloid proteins, e.g. AA amyloidosis.</i><br /><br />So if the mutation is in a gene that expresses an amyloid protein, such as fibrinogen, that is considered hereditary amyloidosis. On the other hand, if the mutation is in genes that do not express amyloid proteins, that is considered familial amyloidosis. I do not know enough about what are now considered familial types to go into any more detail on those or discuss how they differ from hereditary types like AFib, so I will just leave it at that and try to use "hereditary" instead of "familial" going forward.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Speaking of familial, I mean hereditary amyloidosis, the next meeting in Chicago has been scheduled for October 28 and 29 of 2017. You can find more information about this meeting and register for it at this link: </span><a href="http://amyloidosissupport.org/support_groups/familial.html" style="font-family: Arial, Helvetica, sans-serif;">http://amyloidosissupport.org/support_groups/familial.html</a><span style="font-family: "arial" , "helvetica" , sans-serif;">. I plan on arriving Friday, October 27, in time for the Friday night meet and greet.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Regarding my health, you may recall from the previous blog post that in October my hemoglobin had increased to 14.3 (within normal range) and my ferritin had increased to 15 (still a little low). I continued taking two iron supplements per day and saw my hematologist, Dr. C, on December 16. My hemoglobin increased to 15.3 and my ferritin increased to 28.1. The normal range for ferritin is 22 to 415, so my ferritin was back in the normal range, as were all the other measurements of things like red blood cell size. So I am going to stop taking the iron supplements on January 1 and see where my numbers are at my annual physical exam in February of 2017.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Next month's post will be the 2016 wrap-up.<br /><br />=====Monthly Blog Status Update=====<br />As of November 30, 2016:<br /><br />Total posts: 172 (1 in October)<br /><br />Total pageviews: 51,400 (~1300 in November)<br /><br />Email subscribers: 14 (unchanged)<br /><br />Total number of countries that have viewed the blog: 132<br /><br />One new country viewed the blog in November:<br /><br /><a href="https://en.wikipedia.org/wiki/Bosnia_and_Herzegovina">Bosnia & Herzegovina</a><br />=====</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: "arial" , "helvetica" , sans-serif;">(1) </span><span style="background-color: white; text-indent: -48px;">Sipe JD, Benson MD, Buxbaum JN, et al. Amyloid fibril proteins and amyloidosis: chemical identification and clinical classification International Society of Amyloidosis 2016 Nomenclature Guidelines. </span><i style="background-color: white; text-indent: -48px;">Amyloid. </i><span style="background-color: white; text-indent: -48px;">2016;23(4):209-213.</span></span></div>
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Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-38299393508310076572016-11-30T23:30:00.000-05:002018-09-06T07:04:43.578-04:00Dallas Support Group Meeting: November 12, 2016<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;">Greetings, loyal blog readers. Long time no see. You may have noticed I did not have a new post in October. No need to fear, though. Although things are a little crazy here for a number of reasons, making it all too easy to put the blog on the back burner, everything is fine.</span><br />
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<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;">Today's post will be an update on my anemia situation, followed by my account of the Dallas support group meeting in November. Since I did not post anything in October, the end of this post will have the monthly blog stats for not just one but two months. Bonus!</span><br />
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<span style="color: #222222; font-family: "arial" , "helvetica" , sans-serif;"><span style="background-color: white; font-size: 13.2px;">In the previous post I mentioned that I started taking iron supplements in September at the recommendation of my hematologist, Dr. C. In September my hemoglobin had increased slightly to 13.3, but my ferritin was 5, which is very low. (Normal for men is 18 to 270.) I saw Dr. C in October after one month of taking the iron supplements, and my hemoglobin had increased to 14.3, which is within the normal range. My ferritin was still a little low at 15, but that definitely indicates the iron supplements are working and my iron storage is improving. Dr. C wants me to continue taking the iron supplements and see him again toward the end of December. So all that is good news. Hopefully I can stop taking the iron supplements in December and everything will be back to normal for my next annual physical exam in February or March of 2017.</span></span><br />
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<span style="color: #222222; font-family: "arial" , "helvetica" , sans-serif;"><span style="background-color: white; font-size: 13.2px;">The Dallas support group meeting was held on November 12, 2016. There were 22 attendees, including the guest speaker, Dr. Gonsalves from Mayo Clinic in Rochester. Fourteen of the 22 attendees were amyloidosis patients, with about half of those being diagnosed with AL amyloidosis. There were a few localized and some ALECT2 patients, and unless I missed hearing about someone's diagnosis, I think I was the only familial patient there.</span></span><br />
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<span style="color: #222222; font-family: "arial" , "helvetica" , sans-serif;"><span style="background-color: white; font-size: 13.2px;">Dr. G's presentation focused primarily on AL amyloidosis and current clinical trials, but it did include some slides about ALECT2, which he spent some time discussing since there were three ALECT2 patients at the meeting. ALECT2 is a relatively new type of amyloidosis that may turn out to be the third most common type. An interesting fact about ALECT2 is that it seems to have a genetic component although it does not appear to be the result of an inherited mutation like ATTR or fibrinogen amyloidosis. I suspect we will start hearing much more about ALECT2 in the general amyloidosis discussions going forward.</span></span><br />
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<span style="color: #222222; font-family: "arial" , "helvetica" , sans-serif;"><span style="background-color: white; font-size: 13.2px;">That's all for now. See you next month. Maybe . . .</span></span><br />
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<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;">=====Monthly Blog Status Update=====</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">As of September 30, 2016:</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total posts: 171 (1 in September)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total pageviews: 48,300 (~1700 in September)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Email subscribers: 14 (unchanged)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total number of countries that have viewed the blog: 131</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">One new country viewed the blog in September:</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><a href="https://en.wikipedia.org/wiki/Turkmenistan" target="_blank">Turkmenistan</a></span><br />
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<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;">=====Monthly Blog Status Update=====</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">As of October 31, 2016:</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total posts: 171 (0 in October)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total pageviews: 50,000 (~1700 in October)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Email subscribers: 14 (unchanged)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total number of countries that have viewed the blog: 131</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">No new countries viewed the blog in October.</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">=====</span>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-49454522346198265132016-09-30T23:40:00.000-04:002016-09-30T23:40:44.329-04:00Tony Stark<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px;">This blog post will just be an update on me followed by the always exciting monthly blog stats at the end. But before getting to that, I need to let everyone know that it is time to start making plans to attend the next mega-gigantic-colossal familial amyloidosis support group meeting in Chicago, scheduled for the last weekend in October of 2017. Details will be available at this link: </span><span style="color: #222222; font-family: "arial" , "helvetica" , sans-serif;"><span style="font-size: 13.2px;"><a href="http://amyloidosissupport.org/support_groups/familial.html" target="_blank">http://amyloidosissupport.org/support_groups/familial.html</a>.</span></span><br />
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<span style="color: #222222; font-family: "arial" , "helvetica" , sans-serif;"><span style="font-size: 13.2px;">In the previous blog post I mentioned that my primary physician drew some blood on August 25 to see what my anemia situation was. On September 2 I found out that my hemoglobin was actually up a little to 13.3 (compared to 12.6 in March) but some of the other numbers still indicated an issue with iron storage. My primary physician recommended I see a hematologist, and I chose to see Dr. C, the same hematologist/oncologist that Mom saw when she had breast cancer and when she was first diagnosed with amyloidosis.</span></span><br />
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<span style="color: #222222; font-family: "arial" , "helvetica" , sans-serif;"><span style="font-size: 13.2px;">My hematologist appointment was September 9. I told Dr. C about the fibrinogen amyloidosis and the fact that anemia often develops in AFib patients after the kidney problems appear, and I do not have any kidney problems yet. He said he thinks my iron deficiency anemia was really caused by the blood donations last year that got my hemoglobin low. My ferritin level, which is an indication of how much iron the body is storing, is at 5. That is very low compared to the low end of the normal range, which is around 20. He explained that although the hemoglobin is on the rise, my body is having a very difficult time recovering and bringing the iron storage levels back into the normal range, which is not unusual. Often it needs a boost, which I do recall from when Mom's hemoglobin started dropping below 10.</span></span><br />
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<span style="color: #222222; font-family: "arial" , "helvetica" , sans-serif;"><span style="font-size: 13.2px;">Dr. C suggested I start taking iron supplements, and then if my iron situation does not resolve itself quickly enough they can do an iron infusion via IV to bring the iron levels back up. So I started taking an iron supplement the following day (one tablet per day), and then increased it to two tablets per day a week later. He said some people are unable to take two tablets per day due to the side effects (primarily constipation), but so far my side effects are negligible. I will have some more lab work done on October 13 to see how things are going.</span></span><br />
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<span style="color: #222222; font-family: "arial" , "helvetica" , sans-serif;"><span style="font-size: 13.2px;">That's all for now. See you next month.</span></span><br />
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<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">=====Monthly Blog Status Update=====</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">As of August 31, 2016:</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total posts: 170 (1 in August)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total pageviews: 46,500 (~1800 in August)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Email subscribers: 14 (unchanged)</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Total number of countries that have viewed the blog: 130</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">Two new countries viewed the blog in August:</span><br />
<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="background-color: white; font-size: 13.2px; line-height: 18.48px;"><a href="https://en.wikipedia.org/wiki/Martinique" target="_blank">Martinique</a></span></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="background-color: white; font-size: 13.2px; line-height: 18.48px;"><a href="https://en.wikipedia.org/wiki/Trinidad_and_Tobago" target="_blank">Trinidad & Tobago</a></span></span><br />
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<span style="background-color: white; color: #222222; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;">=====</span>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0tag:blogger.com,1999:blog-4284577738924004196.post-40473329415430914582016-08-31T23:54:00.000-04:002016-08-31T23:54:23.821-04:00Article Review (2013) - Renal Transplantation in Systemic Amyloidosis -- Importance of Amyloid Fibril Type and Precursor Protein Abundance<span style="font-family: "arial" , "helvetica" , sans-serif;">Today's post will be a quick update on me, followed by an article review, ending with the always exciting blog status update at the end.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">As mentioned in the previous post, on July 28 I had my second capsule endoscopy due to a malfunction with the first one. The gastroenterologist, Dr. E, called me early the next week and said no abnormalities were found. We then discussed what the next step should be, and we agreed that I would see my primary physician to discuss whether to refer me to a hematologist, have me start taking an iron supplement, or do something else.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">I saw my primary physician on Thursday, August 25, and as I expected he wanted to do some blood work to see where my hemoglobin level is now. I asked him to also have my creatinine and GFR measured with that blood work and explained why. My most recent lab work was done in March of this year, so this set of numbers will give another data point 5 to 6 months after that. I do not have those results yet, so we will have to wait until the next blog post to see what happens next. Now to the article review . . .</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Title:</b> Renal Transplantation in Systemic Amyloidosis -- Importance of Amyloid Fibril Type and Precursor Protein Abundance (1)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Authors:</b> Pinney, Lachmann, Sattianayagam, Gibbs, Wechalekar, Venner, Whelan, Gilbertson, Rowczenio, Hawkins, and Gilmore (UK National Amyloidosis Centre, London, UK; UCL Centre for Nephrology, London, UK)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Journal:</b> American Journal of Transplantation (February 2013)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Abstract:</b></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><i><br /></i></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><i>Renal transplantation remains contentious in patients with systemic amyloidosis due to the risk of graft loss from recurrent amyloid and progressive disease. Outcomes were sought among all patients attending the UK National Amyloidosis Centre who received a renal transplant (RTx) between January 1978 and May 2011. A total of 111 RTx were performed in 104 patients. Eighty-nine percent of patients with end-stage renal disease (ESRD) due to hereditary lysozyme and apolipoprotein A-I amyloidosis received a RTx. Outcomes following RTx were generally excellent in these diseases, reflecting their slow natural history; median graft survival was 13.1 years. Only 20% of patients with ESRD due to AA, AL and fibrinogen amyloidosis received a RTx. Median graft survival was 10.3, 5.8 and 7.3 years in these diseases respectively, and outcomes were influenced by fibril precursor protein supply. Patient survival in AL amyloidosis was 8.9 years among those who had achieved at least a partial clonal response compared to 5.2 years among those who had no response (p = 0.02). Post-RTx chemotherapy was administered successfully to four AL patients. RTx outcome is influenced by amyloid type. Suppression of the fibril precursor protein is desirable in the amyloidoses that have a rapid natural history.</i></span></blockquote>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Here is a link to the article: </span><a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2012.04326.x/full" target="_blank">http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2012.04326.x/full</a><br />
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As stated in the abstract, this article reviews the results of renal transplants among UK National Amyloidosis Centre patients between January of 1978 and May of 2011. There were 111 transplants among 104 patients with various types of systemic amyloidosis. The breakdown among the five different types of systemic amyloidosis that were represented is as follows:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">AL (primary) - 25 patients</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;">AA (secondary) - 43</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;">AFib (fibrinogen) - 19</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;">AApo (Apolipoprotein A1) - 14</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;">ALys (Lysozyme) - 3<br /><br /><br />The main focus of this article is to document the results of these kidney transplants and see how the type of amyloid protein and the presence of that protein post-transplant affects how well the transplanted kidney performs. In this review I will only be focusing on the results of the AFib patients.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The introduction of the article provides some basic information about the various types of amyloidosis. It mentions three important points about fibrinogen amyloidosis that differentiate it from the other types:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"> - AFib presents with proteinuria and progressive decline in kidney function, usually leading to end-stage renal disease within five years of diagnosis.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"> - The fibrinogen alpha-chain is synthesized only in the liver.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"> - Since fibrinogen alpha-chain is only synthesized in the liver, liver transplantation completely eliminates the mutant fibrinogen molecules from being produced.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Here are some of the statistics regarding the 19 AFib patients included in this study:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"> - There were a total of 21 renal transplants among the 19 patients, indicating some transplanted kidneys failed.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"> - Nine patients received combined liver and kidney transplants. (One of those was after a transplanted kidney developed amyloid.)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"> - Amyloid did reoccur in seven patients who received kidney transplants, but not in any of the patients who received combined liver and kidney transplants.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"> - 4 of the 10 patients who received kidney transplants had died as of the writing of the article. None of those deaths were known to be due to surgical complications. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"> - 3 of the 9 patients who received combined liver and kidney transplants died due to surgical complications.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The discussion section of the article mentions again that liver transplantation removes all of the mutant fibrinogen from the blood, preventing the ongoing accumulation of amyloid in the kidneys. But it states that the risk of combined liver and kidney transplant must be considered when deciding on kidney only vs. combined liver and kidney. This article does not mention anything about liver only transplantation, which is not surprising since it was published in 2013 and came out of the NAC in London.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">This article does not really give us any new information on fibrinogen amyloidosis itself, but it does provide some statistics (from a small population) on the mortality of two treatment options (kidney transplant vs. combined liver and kidney transplant). That serves as a helpful reminder that although we hear about organ transplants quite frequently in the amyloidosis community, organ transplants are certainly not without risk.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Next up will hopefully be an update on me.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">=====Monthly Blog Status Update=====</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">As of July 31, 2016:</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">Total posts: 169 (1 in July)</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">Total pageviews: 44,600 (~2300 in July)</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">Email subscribers: 14 (unchanged)</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">Total number of countries that have viewed the blog: 128</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">One new country viewed the blog in July:</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://en.wikipedia.org/wiki/Seychelles" target="_blank">Seychelles</a></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Citation:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">(1) Pinney, J. H., Lachmann, H. J., Sattianayagam, P. T., Gibbs, S. D. J., Wechalekar, A. D., Venner, C. P., Whelan, C. J., Gilbertson, J. A., Rowczenio, D., Hawkins, P. N. and Gillmore, J. D. (2013), Renal Transplantation in Systemic Amyloidosis—Importance of Amyloid Fibril Type and Precursor Protein Abundance. American Journal of Transplantation, 13: 433–441. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>Davidhttp://www.blogger.com/profile/00594087789704878033noreply@blogger.com0